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An Assessment of Smoke-Free Signage in Gainesville Public Parks

Permanent Link: http://ufdc.ufl.edu/UFE0044313/00001

Material Information

Title: An Assessment of Smoke-Free Signage in Gainesville Public Parks
Physical Description: 1 online resource (104 p.)
Language: english
Creator: Platter, Heather N
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: amenity -- behavior -- ets -- florida -- hbm -- healthbeliefmodel -- outdoor -- parks -- passive -- policy -- secondhand -- ses -- shs -- signage -- smoke -- smoke-free -- smoking -- socioeconomicstatus -- tobacco
Family, Youth and Community Sciences -- Dissertations, Academic -- UF
Genre: Family, Youth and Community Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Secondhand smoke causes 46,000 deaths in nonsmokers within the US every year (USDHHS, 2006). In Florida, 2,750 adult nonsmokers die each year due to secondhand smoke exposure (Florida Charts, 2007). The objective of this study was to evaluate whether Smoke-Free Zone signage posted in park amenities (playgrounds, picnic pavilions, restrooms) would change smoking behaviors of park patrons. A time-series quasi-experimental design was used where data were collected at the same time and in the same order every week in 10 amenities from four parks. The four parks served as their own control, and then received the intervention. The researcher collected cigarette butts (n = 2,692) at park amenities (n=10) at baseline and follow-up in four different public parks. Baseline data were collected until a stable trend emerged, which was established at 6 weeks; signs were then introduced and remained during data collection period. Data collection during the intervention stopped once a stable trend emerged at 6 weeks. Due to not having normally distributed data, the researcher ran several nonparametric Wilcoxon signed-rank tests to test the strength of the mean differences. The Wilcoxon signed-rank test showed that seven out of the ten individual amenities decreased, with one playground, picnic pavilion and restroom that increased. The Wilcoxon signed-rank test determined that the data were significant at p = 0.028. Despite a decrease in means after the implementation of signage, none of the amenities were statistically significant. This study provides some of the first evidence on the impact of smoke-free signage that is not back by law in parks using a reproducible measure. The implications of this study are important for states such as Florida that has pre-emptive clause legislation concerning smoke-free air, since this study researches posted signage that is not backed by law.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Heather N Platter.
Thesis: Thesis (M.S.)--University of Florida, 2012.
Local: Adviser: Fogarty, Kate.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2012-11-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044313:00001

Permanent Link: http://ufdc.ufl.edu/UFE0044313/00001

Material Information

Title: An Assessment of Smoke-Free Signage in Gainesville Public Parks
Physical Description: 1 online resource (104 p.)
Language: english
Creator: Platter, Heather N
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: amenity -- behavior -- ets -- florida -- hbm -- healthbeliefmodel -- outdoor -- parks -- passive -- policy -- secondhand -- ses -- shs -- signage -- smoke -- smoke-free -- smoking -- socioeconomicstatus -- tobacco
Family, Youth and Community Sciences -- Dissertations, Academic -- UF
Genre: Family, Youth and Community Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Secondhand smoke causes 46,000 deaths in nonsmokers within the US every year (USDHHS, 2006). In Florida, 2,750 adult nonsmokers die each year due to secondhand smoke exposure (Florida Charts, 2007). The objective of this study was to evaluate whether Smoke-Free Zone signage posted in park amenities (playgrounds, picnic pavilions, restrooms) would change smoking behaviors of park patrons. A time-series quasi-experimental design was used where data were collected at the same time and in the same order every week in 10 amenities from four parks. The four parks served as their own control, and then received the intervention. The researcher collected cigarette butts (n = 2,692) at park amenities (n=10) at baseline and follow-up in four different public parks. Baseline data were collected until a stable trend emerged, which was established at 6 weeks; signs were then introduced and remained during data collection period. Data collection during the intervention stopped once a stable trend emerged at 6 weeks. Due to not having normally distributed data, the researcher ran several nonparametric Wilcoxon signed-rank tests to test the strength of the mean differences. The Wilcoxon signed-rank test showed that seven out of the ten individual amenities decreased, with one playground, picnic pavilion and restroom that increased. The Wilcoxon signed-rank test determined that the data were significant at p = 0.028. Despite a decrease in means after the implementation of signage, none of the amenities were statistically significant. This study provides some of the first evidence on the impact of smoke-free signage that is not back by law in parks using a reproducible measure. The implications of this study are important for states such as Florida that has pre-emptive clause legislation concerning smoke-free air, since this study researches posted signage that is not backed by law.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Heather N Platter.
Thesis: Thesis (M.S.)--University of Florida, 2012.
Local: Adviser: Fogarty, Kate.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2012-11-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044313:00001


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1 AN ASSESSMENT OF SMOKE FREE SIGNAGE IN GAINESVILLE PUBLIC PARKS By HEATHER NICOLE PLATTER A THESIS PROPOSAL PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGR EE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2012

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2 2012 Heather Nicole Platter

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3 To my bea utiful Mom, Dana Erlene Platter Your life helped my dreams become a reality. May you Rest in Peace 05/01/2011.

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4 ACKNO WLEDGEMENTS The author wis h es to acknowledge the guidance and support of her thesis committee during this process, Dr. Kate Fogarty, Dr. Steven P. Pokorny, and Dr. Karla Shelnutt. An extra special thanks go to Dr. Kate Fogarty for her dedicated effort and seeing that I finish this project and also go to Dr. Steven Pokorny for countless hours of statistics explanations and teachings of how to conduct research in real life for real things. The author also wishes to acknowledge her family as a major support a nd motivator of this project. My Mother passed away from lung cancer in May of 2011 and was a primary reason for my dedication and perseverance in this project. My Father received numerous daily calls on the frustrations, successes, difficulties, and excit ement that have occurred with doing this thesis. He has been my primary support in pushing me to do my best and letting me know that I can do anything. Special thanks also go to Chase Ryant for his participation and help in data collection, presentations, and reviewing my work. You have been a great colleague and friend.

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5 TABLE OF CONTENTS page ACKNOWLEDGEMENTS ................................ ................................ ............................... 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 10 ABSTRACT ................................ ................................ ................................ ................... 11 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 13 Statement of the Problem ................................ ................................ ....................... 13 Policy and Secondhand Smoke Exposure ................................ .............................. 15 Outdoor Smoke Free Policies ................................ ................................ ................. 16 Signage and Behavior Change ................................ ................................ ............... 17 Purpose ................................ ................................ ................................ .................. 18 Research Questions ................................ ................................ ............................... 18 Significance ................................ ................................ ................................ ............ 18 Hypotheses ................................ ................................ ................................ ............. 19 2 REVIEW OF LITERATURE ................................ ................................ .................... 20 Introduction and Statement of the Problem ................................ ............................. 20 Exposure of Secondha nd Smoke ................................ ................................ ........... 22 Epidemiology of Secondhand Smoke in Florida ................................ ..................... 24 Safe Level of and Exposure to Secondhand Smoke ................................ ............... 24 Harmful Chemicals of Secondhand Smoke ................................ ............................ 26 Health Effects of Exposure to Secondhand Smoke ................................ ................ 26 Disparities in Secondhand Smoke Exposure ................................ .......................... 31 Economic Costs and Benefits of Secondhand Smoke ................................ ............ 33 Laws Regarding Exposure to Secon dhand Smoke ................................ ................. 34 Current Literature Review ................................ ................................ ....................... 36 Signage and Behavior Change ................................ ................................ ............... 40 The Health Belief Model ................................ ................................ .......................... 44 3 METHODS ................................ ................................ ................................ .............. 47 Purpose ................................ ................................ ................................ .................. 47 Design ................................ ................................ ................................ ..................... 47 Sample Selection ................................ ................................ ................................ .... 48 Population ................................ ................................ ................................ ........ 48

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6 Sample ................................ ................................ ................................ ............. 48 Collection Zones ................................ ................................ ................................ ..... 49 Procedure ................................ ................................ ................................ ............... 52 Data Collection ................................ ................................ ................................ ....... 54 Sign Development ................................ ................................ ................................ .. 55 Data Analysis ................................ ................................ ................................ .......... 55 4 RESULTS ................................ ................................ ................................ ............... 57 5 DISCUSSION ................................ ................................ ................................ ......... 67 Main Findings ................................ ................................ ................................ ......... 67 Other Findings ................................ ................................ ................................ ........ 69 Implic ations ................................ ................................ ................................ ............. 70 Limitations ................................ ................................ ................................ ............... 74 Future Research ................................ ................................ ................................ ..... 75 APPENDIX A TABLES AND F IGURES ................................ ................................ ........................ 77 B NO SMOKING SIGNAGE ................................ ................................ ....................... 80 C PARK SAMPLE SELECTION LIST: ................................ ................................ ....... 81 D IRB APPROVAL ................................ ................................ ................................ ..... 83 E PHOTOS ................................ ................................ ................................ ................ 85 LIST OF REFERENCES ................................ ................................ ............................... 89 BIOGRAPHICAL SK ETCH ................................ ................................ .......................... 104

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7 LIST OF TABLES Table page 2 1 The health belief model and smoking in park amenities ................................ ..... 45 4 1 Parks and amenities ................................ ................................ ........................... 57 4 2 Cigarette butts collected by amenity ................................ ................................ ... 58 4 3 Cigarette butts collected by amenity during baseline ................................ .......... 58 4 4 Cigarette butts collected by amenity after signage placement ............................ 58 4 5 Ranks comparing baseline data collection with signage data collection. ............ 59 4 6 Test statistic of overall amenities ................................ ................................ ........ 59 4 7 Ranks of picnic pavilion amenity ................................ ................................ ......... 61 4 8 Test statistic of picnic pavilion amenity ................................ ............................... 61 4 9 Ranks of playground amenity ................................ ................................ ............. 61 4 10 Test statistic of playground amenity ................................ ................................ ... 62 4 11 Ranks of restroom amenity ................................ ................................ ................. 62 4 12 Test statistic of restroom amenity ................................ ................................ ....... 62 4 13 Ranks of Northeast park ................................ ................................ ..................... 64 4 14 Test statistic of Northeast park ................................ ................................ ........... 64 4 15 Ranks of Possum park ................................ ................................ ....................... 64 4 16 Test statistic of Possum park ................................ ................................ .............. 65 4 17 Ranks of Greentree park ................................ ................................ .................... 65 4 18 Test statistic of Greentree park ................................ ................................ ........... 65 4 19 Ranks of Roper park ................................ ................................ ........................... 66 4 20 Test statistic of Roper park ................................ ................................ ................. 66 A 1 Baseline, no signage ................................ ................................ .......................... 77 A 2 Intervention, with signage ................................ ................................ ................... 77

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8 A 3 Amount of signs per amenity in each parks ................................ ........................ 77 C 1 Park sample selection list ................................ ................................ ................... 81

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9 LIST OF FIGURES Figure page 2 1 Steps linking secondhand smoke exposure and cancer ................................ ..... 30 4 1 Box plots of cigarette butts during control at different parks .............................. 60 4 2 Box plots of cigarette butts during the intervention at different parks ................ 60 4 3 Box plots of cigarette butts during control at different amenities ........................ 63 4 4 Box plots of cigarette butts during intervention at different amenities ................ 63 A 1 Average annual number of deaths due to smoking ................................ ............ 78 A 2 Secondhand smoke graphic ................................ ................................ ............... 78 A 3 Preemption of local smoke free indoor air ordinances ................................ ........ 79 B 1 Example of signage ................................ ................................ ............................ 80 B 2 Example of signage ................................ ................................ ............................ 80 B 3 Signage used in project ................................ ................................ ...................... 80 D 1 IRB approval 1 ................................ ................................ ................................ .... 83 D 2 IRB approval 2 ................................ ................................ ................................ .... 84 E 1 Playground sign ................................ ................................ ................................ .. 85 E 2 Playground sign ................................ ................................ ................................ .. 85 E 3 Playground sign ................................ ................................ ................................ .. 86 E 4 Picnic pavilion signs ................................ ................................ ........................... 86 E 5 Picnic pavilion sign ................................ ................................ ............................. 87 E 6 Playground sign ................................ ................................ ................................ .. 87 E 7 Cigarette butts ................................ ................................ ................................ .... 88 E 8 Cigarette butts ................................ ................................ ................................ .... 88

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10 LIST OF DEFINITION S C OMPREHENSIVE OUTDOOR SMO KE FREE POLICY : Prohibits smoking in at least five of the seven major outdoor areas: outdoor dining areas, entryways, public events, recreational areas, service areas, sidewalks and worksites (Center for Tobacco Policy, 2010). C UES TO ACTION Cues to action are physical or environmental events that motivate and remind people to take action ( Boen, Maurissen & O pdenacker 2010 ). E NVIRONMENTAL T OBACCO S MOKE : The combination of mainstream and sidestream smoke (USDHHS, 2006). I NVOLUNTARY /P ASSIVE SMOKING : Exposure to environmental tobacco smoke. M AINSTREAM SMOKING : The smoke exhaled from an individual after taki ng a puff on a lit cigarette (USDHHS, 2006). P OINT OF DECISION : An intervention, which alters the physical environment that influences one to make a decision, based on posted signage. In this study, point of decision prompts were signs encouraging smoke f ree zones in parks and were placed where the researcher believed were high intervention zones (Solar et al., 2010). S IDESTREAM SMOKING : The smoke that comes off the end of a lit cigarette (USDHHS, 2006).

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11 Abstract of Thesis Presented to the Graduate Scho ol of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science AN ASSESSMENT OF SMOKE FREE SIGNAGE IN GAINESVILLE PUBLIC PARKS By HEATHER NICOLE PLATTER May 2012 Chair: Kate Fogarty Major: Family, Youth and Community Sciences Secondhand smoke causes 46,000 deaths in nonsmokers with in the US e very year (USDHHS, 2006). In Florida, 2,750 adult nonsmokers die each year due to secondhand smoke exposure (Florida Charts, 2007). The objective of t his study was to evaluate whether Smoke Free Zone signage p osted in park amenities (playgrounds, picnic pavilions, restrooms) would change smoking behaviors of park patrons A time series quasi experimental design was used where data w ere collected at the same time and in the same order every week in 10 amenities from four parks. The four parks served as a baseline and then received the intervention. The researcher collected cigarette butts (n = 2,692) at park amenities (n=10) at baseline and follow up in four different public parks. Baseline data were collected until a stable trend emerged, which was established at 6 weeks; signs were then introduced and remained during data collection period. Data collection during the intervention stopped once a stable trend emerged at 6 weeks. Due to not having normally distributed data, the researcher ran several nonparametric Wilcoxon signed rank tests to test the strength of the mean differences The Wilcoxon signed rank test showed that smoking at seven out of the ten individual

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12 amenities decreased, with smoking at one playground, picnic pavilion and restroom that increased The Wilcoxon signed rank test determined that the data we re significant at p = 0.028. However, grouped amenities (playgrounds, picnic pavilions restrooms) did not experience a statistically significant change. This study provides some of the first evidence on the impact of smoke free signage that is not back ed by law in parks using a reproducible measure. The implications of this study are impor tant for states such as Florida that has pre emptive clause legislation concerning smoke free air since this study researches posted signage that is not backed by law.

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13 CHAPTER I I NTRODUCTION Statement of the Problem Environmental tobacco smoke (ETS), al so known as secondhand smoke, is a prevalent yet avoidable health risk within the United States (Glantz & Parmley, 2001). Cigarette smoking and involuntary exposure to secondhand smoke is accountable for approximately 443,000 deaths each year within the Un ited States, making it of top precedence to public health officials (See Figure A 1) ( Adhikiari, Kahende, Malarcher, Husten & Asman, 2009 ; Dube et al., 2010 ). Smoking not only harms the health of smokers but the effects of secondhand smoke are deleterious to non smokers Infants and children are at high risk of disease due to secondhand smoke. Sixty percent of, or approximately 22 million, children in the U.S. are currently exposed to tobacco smoke (USDHHS, 2006). Childre n who are exposed to secondhand smo ke have an increased risk for health problems and diseases including sudden infant death syndrome (SIDS) (430 cases/yr); acute respiratory infections; ear infections (+750,000 cases/yr); and severe asthma with more attacks and higher severity in 200,000 up to 1 million children (American Cancer Society, 2010; CEPA, 200 6 ). Secondhand smoke exposure in children under 18 months old has caused anywhere between 50,000 to 300,000 lung infections resulting in 7,500 to 15,000 hospitalizations annually (America n Can cer Society, 2010). Adults also experience negative health effects fr o m secondhand smoke. Lam and colleagues (2005) researched secondhand smoke and association with respiratory symptoms. The researchers used a standardized questionnaire on secondhand smok e

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14 researchers reported that secondhand smoke exposure was strongly associated with an increased amount of respiratory symptoms such as coughing, throat problems and wheezing (Lam et al., 2005). Secondhand smoke is also known to cause lung cancer in nonsmokers. T he U.S. EPA report Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders revealed that secondhand smoke is a human lung carcinogen that is respo nsible for lung cancer, which causes approximately 3,000 deaths a year (EPA, 2010). Secondhand smoke also causes 46,000 deaths due to heart disease each year (California Environmental Protection Agency [CEPA], 2006). Exposure to secondhand smoke can immed vessels and increasing their risk of heart disease by 25 to 30 percent (USDHHS, 2006). The adverse effects of these chemicals alter the cardiovascular system in the short term and cause coron ary heart disease in the long term (USDHHS, 2006). Even minimal intake of secondhand smoke has negative effects that alter normal functioning of the heart, blood, and vascular systems that increase the risk of a heart attack (USDHHS, 2006). Dube and colle agues (2010) used the 2009 National Health Interview Survey and the Behavioral Risk Factor Surveillance System to estimate national smoking prevalence. The results state that a pproximately 46.6 million U.S. adults smoke and that prior declines in smoking r ates have stopped going down (Dube et al., 2010) Dube and colleagues (2010) found that an estimated 88 million nonsmoking American citizens are involuntarily exposed to environmental tobacco smoke The Center s for Disease Control and Prevention recommends laws and policies to protect the public from secondhand

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15 smoke exposure as well as cessation steps for current smokers an d prevention strategies to keep young people from smoking The Centers for Disease Control and Prevention (2011) suggests policy change s that include increasing the unit price of tobacco products; implementing smoke free policies, regulations, and laws; providing insurance coverage of tobacco use treatment; and limiting min products. Policy and Secondhand Smoke Expos ure The Surgeon General p assed a federal smoking ban in 1971, and since then there have been reductions in smoking in sites such as work places, schools, bars, and restaurants (USDHHS, 2006). As of April 2011, 3,270 municipalities within the United States Foundation [ANR], 2010 These indoor smoking bans were a positive stride towards Glantz, 2002; Bauer, Hyland Li Steger & Cummings 2005). The 1986 report of the Surgeon General, The Health Consequences of Involuntary Smoking (USDHHS, 2006), stated that the separation of smokers and nonsmokers exposure to secondhand smoke. There has been a strong momentum to regulate smoking inside public settings but regulation of smoking in outdoor environments has not been studied until recently ( Tynan, Babb, MacNeil, & Griffin 2011). Even though there has been development towards smoke free spaces indoors and outdoors in public spaces in the U.S., cigarette smoking and secondhand smoke still remain burde nsome public health concerns.

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16 Outdoor Smoke Free Policies Although restaurants, businesses, and schools have smoke free policies for indoor areas, there is little information on acceptance and compliance with such policies for outdoor areas. Studies of effectiveness of outdoor smoke free policies and successful approaches to enforce outdoor smoking bans are limited and have conflicting results. McMillen and colleagues (2003) researched adult attitudes and practices regarding smoking restrictions to limit child exposure to environmental tobacco smoke in outdoor spaces but it did not research complianc e with the smoking restrictions. The authors reported that the majority of adults within the study were ignorant of the harmful effects of children exposed to secondhand smoke. However, the majority favored public smoking restrictions that advocates suppor t for restriction policies (McMillen, Winickoff, Klein & Weitzman, 2003). Although outside policies concerning secondhand smoke are limited, they are Ott & Switzer, 2007 p.522 ). Many researchers are discussing whether smoking should be prohibited in outdoor areas although there is no current consensus (Bloch & Shopland, 2000; Chapman, 2000; Chapman 2008; Thompson, Willson & Edwards, 2008). Despite mi nimal research, governments within the U.S. are enacting smoking bans in outdoor areas like parks and beaches and outdoor areas around building entrances, schools and hospitals (Globalsmokefree Partnership, 2009). Cities such as New York are leading such t obacco bans in parks and beaches (Scheck & Colvin, 2011). Building entrances and outdoor areas of schools and hospitals often have high levels of secondhand smoke due to indoor smoking bans. The high levels of secondhand smoke outside of buildings is a con sequence of

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17 implementing indoor smoking bans but not outdoor property smoking bans (Brennan et al, 2010; Cameron et al., 2010; Repace, 2005). College campuses are also increasingly incorporating smoke free campus policies to decrease secondhand smoke (ANR 2011). Although many policies concerning smoke free campuse s are being developed and implemented, research addressing the outcomes and impacts of these policies are limited (Seo, Macy, Torabi & Middlestadt, 2011) Signage and Behavior Change Point of de cision posted signage is used to change multiple types of behaviors (Nomura, Yoshimoto, Aezaki & Sato 2009; Ford & Torok, 2008; Boen, Maurissen & Opdenacker 2010). Signs with health promoting messages have been found to have a positive effect on behavi or change (Nomura et al, 2009; Ford & Torok, 2008; Boen et al., 2010). A good portion of research examines the behavior change effects of signs, but there is limited research on antismoking signage and behavior change. Research concerning public attitudes towards tobacco free park policies is growing in prevalence (Klein, Forster, McFadden & Outley, 2006). Klein and colleagues (2006) conclude that there is large public support of tobacco free park policies, yet there are doubts concerning compliance. Har ris and colleagues (2009) researched compliance of an outdoor smoking ban with a multicomponent approach, which included signage. Results demonstrated that the use of multiple components increased compliance with the non smoking policy (Harris, Stearns, Ko vach & Harrar, 2009) yet there was not enough evidence to discern which approach was most beneficial. Therefore, it is important to research individual approaches then possibly combine them in the future to test results of thes e combined

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18 effects. This res earch will elaborate on the posted signage method of the multicomponent approach used by Harris and colleagues (2009). Purpose The purpose of this study is to examine whether posted signage in selected amenities can alter smoking behaviors of patrons of p arks within a suburban area in Florida. This study used one specific sign for this experiment (see Appendix B for sign ). The phrase that was used on the sign was chosen based on recommendations from literature (Jacobson et al., 2007) City Commissions and the Director of Parks, Recreation and Cultural Affairs Department for the city parks in the study. This study will allow for a better understanding of whether a passive method such as signage can alter, or decrease smoking behavior among park patrons. Re search Questions The question s that form the basis of this study are : 1. Does smoke fre e zone signage placed at points of decision in Gainesville public parks decrease smoking within and around selected amenities (e.g. restrooms, playgrounds, picnic areas?) 2. H ow might smoking differ between amenities as a result of introduction of signs to parks ? Significance This study aspires to generate knowledge about the effects of posted signage for altering individual smoking behavior. Learning about these effects will d etermine whether posted signage is associated with reduced smoking and therefore, secondhand smoke exposure of patrons in parks. F urthermore there is currently no published research on smoke free zone signage where there is no policy to back up the signs. This study provides some of the first evidence on possible impact s of smoke free zone

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19 signage in outdoor public parks where policy is lacking using a reproducible methodology Smoke free zone signage in city parks, which lack policies for outdoor smoking may or may not have an impact on park patrons. Hypotheses 1. Null Hypothesis: Presence of signs will have no effect on smoking in parks. Alternative Hypothesis: Presence of signs will have an effect on smoking in parks compared to control. 2. Null Hypothesis : Provided there is evidence to support the first alternative hypothesis in which a reduction in the number of cigarette butts is found in points of decision from baseline to when signs are placed in parks, the likelihood of reduction in smoking across amen ities will be equal (playground, bathrooms, and picnic areas). Alternative Hypothesis: Provided support is found for the first alternative hypothesis playground amenities, compared to bathrooms and picnic areas will have the greate st reduction in number o f cigarette butts found between baseline data collection and signage placement data collection

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20 C HAPTER 2 REVIEW OF LITERATURE Introduction and Statement of the Problem This literature review assesses secondhand smoke and its effects on the body along with evaluations of current research and policies on secondhand smoke in outdoor settings Since there is a limited amount of research on smoke free signage in relation to behavior change, th is review will also assess other studies that have used signage in or der to alter behavior s. Furthermore, it will introduce the Health Belief Model theoretical framework, which ha s been used and applied to multiple research studies concerning health related behavior change. There is currently little to no research on the e ffects of outdoor smoking policies and recommendations on altering behavior s ( Lee et al. 2011; McMillen, Winickoff, Klein & Weitzman, 2003; Seo et al., 2011). Researchers are starting to interview people on their a ttitudes and beliefs on tobacco policies but there is limited research regarding altering smoking behavior changes in outdoor settings ( Lee et al. 2011; McMillen et al., 2003; Seo et al., 2011). The current research ex amines the effects of smoke free zone signage that is not ba cked up by policy or ordinances on the behaviors of tobacco smoking individuals in public parks. In this research, there are no formal consequences (e.g. monetary/legal sanctions) placed up on park patrons who smoke. Inf ormal consequences such as non smoki ng park patrons referring smokers to the posted smoke free zone signage or asking them to refrain from smoking may occur T hese informal consequences may cause smokers to refrain from smoking or move their smoking behavior away from amenities where signs a re posted

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21 Tobacco use and secondhand smoke is a leading, yet preventable, cause of death in the United States with over 443,000 premature deaths related to smoking each year ( See Figure A 1 in Appendix A) ( Adhikiari, Kahende, Malarcher, Pechacek & Tong, 2008 ). Globally smoking kills more than 5 million people a year (World Health Organization [ WHO ] 2007). Adhik i ari and colleagues (2008) estimated this number will increase to 8 million by the year 2030 and th en four out of five deaths will be related to tobacco use. Surgeon General Leroy E. Burney issued the first official federal statement in 1957 that smoking causes lung cancer (USDHHS, 2007). Since 1964, the Surgeon General has published over 30 separate reports on tobacco smoke, each containing more i nformation on the linkages between tobacco and health problems related to use or exposure (USDHHS, 2012 ). Approximately 30 years later, researchers have discovere d that secondhand smoke causes cancer, among other diseases, in individuals who do not smoke or use tobacco products ( Adhikiari et al., 2008 ). Adhikiari and colleagues (2008) work using the National Health Interview Survey and the National Center for Health Statistics death certificate dat a estimated that s econdhand smoke is the caus e of 50,000 annual deaths in nonsmokers In 1986, the Surgeon General announced that secondhand smoke causes cancer and other health effects in non smokers (ANR, 2012). Secondhand smoke is defined as a combination of gases and fine particles from smoke ex haled by the smoker (mainstream smoke) and smoke from a lit tobacco product (sidestream smoke) ( See Figure A 2 in Appendix A ) (National Toxicology Program, 2011; USDHHS, 2 006; American Lung Association [ ALA ] 2007; Glantz & Parmley, 2001). These two forms of smoke are not the same. Carcinogens are found in higher concentrations within

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22 sidestream smoke, which contains smaller particles that make it easier to enter cells within the body (American Cancer Society, 2010). Secondhand smoke is also called environm ental tobacco smoke (ETS), involuntary smok ing and passive smok ing (ALA, 2007; Glantz & Parmley, 2001). The terms involuntary smoking and passive smoking describe non smokers exposed to secondhand smoke (American Cancer Society, 2010). The most prevalent s ources of secondhand smoke are cigarettes, followed by pipes and cigars (USDHHS, 2006). Exposure of S econdhand S moke People can experience exposure to secondhand smoke regardless of whether there are laws regarding smoking in a given area. Most often indi viduals are exposed to secondhand smoke in their homes and cars or public places such as recreational settings, parks, restaurants and bars ( Chriqui, Babb, Blair, Vaughn & MacNeil, 2005 ). Children and adults experience high amounts of secondhand smoke with in the home, although children suffer the most from exposure because of their developing organs ( Aligne & Stoffard, 1997; Levy, Rigotti & Winickoff, 2011; Jarvie & Malone, 2008; USDHHS, 2006). The World Health Organization (WHO) approximates that 700 milli on children worldwide are exposed to secondhand smoke in their homes (WHO, 2007). Smoking within cars is a large source of secondhand smoke exposure for both children and adults. Even if a window is rolled down, poisons from secondhand smoke can rise drast ically within the vehicle in minimal time (American Cancer Society, 2010). The California Environmental Protection Agency (CEPA) stated that people are exposed t o the same volume of airborne, secondhand smoke particles within an enclosed car as a firefight ).

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23 The Occupational Safety and Health Administration (OSHA) is the federal agency that regulates the health a nd safety of individuals in the workplace, which is the where nonsmoking adults experience the highest amounts of secondhand smoke exposure (American Cancer Society, 2010). OSHA, along with the National Institute for Occupational Safety and Health (NIOSH) recommends smoke free workspaces due to the numerous carcinogens contained in secondhand smoke (American Cancer Society, 2010). Outdoor secondhand smoke is a controversial topic, which means that research on its effects is greatly needed (Chapman, 1997; Ch apman, 2000; Repace, 2000; Bloch & Shopland, 2000) Chapman (1997; 2000) argu ed that outdoor smoking bans create problems in the community and that there should not be bans in public venues such as beaches, outdoor cafes, or parks. Repace (2000) responded to this argument with the point that banning outdoor smoking is scientifically justifiable due to exposure of high levels of secondhand smoke to nonsmokers. Bloch and S hopland (2000) argued further about secondhand smoke as the main cause of outdoor smokin g bans and discussed the consequences of cigarette butt litter, fire risk, and protecting resident s from nuisances. A recently published study from Stanford reported the levels of outdoor air pollution found from secondhand smoke (Tobacco smoke, 2011). Res ults show that secondhand smoke is high near active smokers, and the levels are compara ble to indoor secondhand smoke. I n addition, sec ondhand smoke contains higher concentrations of carcinogens and toxic chemicals than smoke inhaled directly from cigarett es (Tobacco smoke, 2011; USDHHS, 2006). Such evidence necessitates tak ing

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24 steps in creating smoke free outdoor spaces, such as public parks, to keep non smokers away from environmental tobacco smoke in outdoor spaces Epidemiology of S econdhand Smoke in F lorida Approximately 28,600 Floridian adults die yearly due to complications from their own smoking behavior, which accounts for over $6.32 billion in annual smoking related Florida health care costs (Adhikiari, Kahende, Malarcher, Husten & Asman, 2009 ). A n additional 2,750 adult nonsmokers die each year in Florida from secondhand smoke ( Adhikiari et al., 2009 ). Florida charts (2007) surveys state that 19.3% of Florida residents regard themselves as a current smoker. In addition, 14.9% of Florida residents reported exposure to secondhand smoke within the last seven days (Florida Charts, 2007). Alachua County Florida reports that 15.5% of its residents are smokers. This is lower than the state of Florida average 19.3% of residents who consider themselves a sm oker (Florida Charts, 2007). Approximately 16.4% of residents of the county in which the parks are located reported exposure to secondhand smoke over the last 7 days (Florida Charts, 2007). It is important to note that these statistics do not reflect the m ajority population of approximately 50,000 college students that live in this county. Safe Level of and Exposure to S econdhand Smoke The Surgeon General stated that there is no safe level of secondhand smoke (USDHHS, 2006). Secondhand smoke, no matter how limited exposure is has a direct, harmful effect o n newest report, How Tobacco Smoke Causes Disease by clarifying that minimal exposure of secondhand smoke is indeed harmful. Brief expos ure to secondhand smoke can cause several acute respiratory effects, such as respiratory symptoms

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25 (cough, asthma, wheezing) (Trinder, Croft & Lewis, 2000). Eisner and colleagues (1998) researched the effects of secondhand smoke on adults who already have a sthma. Using a cohort study of 451 nonsmoking adults with asthma, the researchers studied 129 subjects who reported exposure to secondhand smoke. Results demonstrated that exposure to secondhand smoke was associated with worse asthma symptoms, more frequen t hospitalizations or emergency department visits, and an overall worse health status (Eisner, Yelin, Henke, Shiboski & Blanc, 1998). Ventilation systems in buildings, designated areas for smokers, and air cleaning do not reduce or eliminate secondhand sm oke. Secondhand smoke, as stated prior, is a mixture of gases and very small particles that air cleaning systems are unable to remove because of their miniscule size (USDHHS, 2006). The American Society of Heating, Refrigerating and Air Conditioning Engine ers (ASHRAE) states that ventilation technology is not reliable in removing secondhand smoke and reducing health risks to people exposed to it (USDHHS, 2006). Furthermore, the ventilation and air conditioning systems in buildings move secondhand smoke thro ughout the building, meaning that more people will ultimately be exposed to it (USDHHS, 2006). In 2007, the World Health Organization (WHO) recommended that 100% smoke free environments be created in order to eliminate negative health effe cts related to se condhand smoke The 2006 Surgeon General Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, state d that nonsmokers can only be protected from secondhand smo ke is if smoking is eliminated from indoor s paces, although people are also exposed to secondhand smoke in the form of outdo or environmental tobacco smoke. There is a need for more research on

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26 the effects of outdoor tobacco secondhand smoke exposure in order to see the side effects of smaller amount s of outdoor exposure. Harmful Chemicals of S econdhand Smoke The National Toxicology Program (2011) stated that secondhand smoke contains over 4,000 chemical compounds, of which 50 cause cancer and over 200 are poisonous. In 2010, the Surgeon General Repo rt How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking Attributable Disease: A Report of the Surgeon General stated that there are now more than 7,000 chemicals in secondhand smoke with at least 250 being poisonous. Currently the re are at least 69 of carcinogenic compounds in secondhand smoke such as cadmium, benzene, lead, nickel, chromium, cadmium, and polonium 210 (Kim et al., 2001; Wu et al., 1995; Ferri & Baratta, 1966). Health Effects of Exposure to S econdhand Smoke Children review due to the nature of the current study. Children are frequent park attendees meaning that child patrons may experience low to high rates of exposure to secondhand smoke. It is imp ortant to eliminate secondhand smoke since it causes dangerous negative health problems in children ( Jarvie & Malone, 2008; Mannino, Siegel, Husten, Rose & Etzel, 1996; Samet, Lewit & Warner, 1994; Moshammer et al., 2006 ). Many organizations are creating r esolutions to support and adapt laws to prohibit smoking in vehicles containing a minor (Committee on Environmental Health, 1997). The Centers for Disease Control and Prevention recommends laws and policies to protect the public from secondhand smoke expos ure as well as cessation steps for current smokers and prevention strategies to discourage young people from smoking (CDC, 2011).

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27 Children are at risk of several health complications du e to secondhand smoke exposure. They experience frequent ear infections intense recurrent asthma attacks, respiratory symptoms such as coughing, sneezing and shortness of breath, along with respiratory infections like bronchitis and pneumonia ( Jarvie & Malone, 2008; Moshammer et al., 2006; Samet et al., 1994; Mannino et al., 1996; American Academy of Pediatrics [AAP] 1986) There are up to 300,000 annual cases of bronchitis and pneumonia in children and 15,000 hospitalizations annually due to secondhand smoke (American Cancer Society, 2010; EPA, 1992). They also have a highe r chance of sudden infant death syndrome (SIDS) (USDHHS, 2006; American Cancer Society, 2010; EPA, 2005 ; Anderson & Cook, 1997 ). Secondhand smoke also affects the bodily development of children younger than 18 months ( AAP 1986; Mannino et al., 1996; Mosha mmer et al., 2006). Moshammer and colleagues (2006) evaluated the effect of secondhand smoke exposure on lung function ing in 20,000 school aged children in nine different countries with in Europe and North A merica. The researchers report ed that prenatal an d postnatal functioning, and their development. The American Academy of Pediatrics (1986) and Mannino and colleagues (1996) both found that secondhand smoke exposure is associated with slower lung development and an increased risk of respiratory infections. Several research studies have discovered that c hildhood ex posure to secondhand smoke may lead to cancer in adulthood ( Wang et al. 2000; Committee on Environmental Health, 1997 ; Sun et al., 1996 ).

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28 Sudden infant death syndrome (SIDS) is the leading ca use of death in healthy babies ( Anderson, Johnson, & Batal, 2005; Task force, 2005; USDHHS, 2006). Infants exposed to secondhand smoke and mothers who smoke during pregnancy increases the risk of SIDS significantly ( Anderson, Johnson, & Batal, 2005; USDHHS, 2006; USDHHS, 2004; Dejmek et al., 2002). Woodward and Laugesen (2001) and Michell and colleagues (1997) stated that mothers who smoke during pregnancy have the highest risk for SID S. A large case cohort study in New Zealand reviewed all births from 1991 to 1993 and found 2323 SIDS cases in the cohort, which were compared to a control of 1,200 births. The research found that maternal smoking was the strongest risk factor for SIDS (Mi chell, Tuohy, & Brunt, 1997). Anderson and colleagues (2005) researched whether maternal prenatal smoking significantly increases risk of SIDS. The researchers conducted a retrospective cohort study using 10 year data from the Colorado Infant Death Registr y to identify causes of infant death (n=1573) which compared mothers who reported prenatal smoking versus mothers who reported no prenatal smoking. Anderson and colleagues discovered 598 cases of SIDS and that infants born to smoking mothers confirmed an increased risk of SIDS. In the final analysis, the researchers suggested a link between 80% of the SIDS deaths and maternal smoking. Cigarette smoking is responsible for approximately 90% of deaths in adult men and 80% of deaths in adult women res ulting fr om pulmonary disease (COPD) or lung cancer ( Lange, Nyboe, Appleyard, Jensen & Schnohr, 1990 ). Lange and colleagues (1990) conducted a longitudinal study with 7, 420 women and 6,336 men from 1976 to 1978 and then again in 1987. Several men and women died du ring that time, which the

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29 researchers found that COPD related death was associated with cigarette smoke (individuals self reported tobacco use). Research shows that nonsmokers exposed to secondhand smoke have a 20 30% higher chance of developing lung cance r (Zhong, Goldberg, Parent, & Hanley, 2000; Zhong, Goldberg, Gao, & Jin, 1999; Hacksaw, Law, & Wald, 1997). Zhong and colleagues (1999) researched incidences of lung cancer in nonsmoking women who live in China. The researchers utilized a case control stud y of 504 women to evaluate the relationship between lung cancer and exposure to secondhand smoke, which was compared to a control group of 601 nonsmoking women. Exposure to secondhand smoke was assessed through personal interviews with the study participan ts. The research suggests that long term exposure to (2000) did another similar study on exposure of secondhand smoke and the risks of lung cancer using 35 case control and five cohort studies with instances of lung cancer and secondhand smoke exposure from 1981 to 1999. Results suggested that lung cancer risk increases as levels of exposure to secondhand smoke increase (Zhong et al., 2000). Hackshaw and colleagues (1997) sou ght out to estimate the risk of lung cancer in non smokers exposed to secondhand smoke by analysis of 37 epidemiological studies of 4626 nonsmokers. Nonsmokers who lived with a smoker had a 24% increased risk of lung cancer, which was statistically signifi cant at P<0.001 (Hackshaw et al., 1997). cancer each year (Adhik i ari et al. 2008). The following chart shows the steps that link secondhand smoke exposure to cancer.

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30 Figure 2 1: Steps l inking secondhand smoke exposure and cancer via tobacco carcinog e ns (USDHHS, 2006). Secondhand smoke causes death from other diseases as well. Nonsmokers experience a heightened risk (25 30%) of developing heart disease if they are exposed to secondhand sm oke ( Law & Wald, 2003; Law, Morris & Walk, 1997; He et al., 1999; USDHHS, 2006). Coronary heart disease due to secondhand smoke kills approximately 46,000 nonsmokers a year ( Adhikiari et al., 2008 ; American Cancer Society, 2010). When nonsmokers are expose d to secondhand smoke, the smoke automatically makes rt disease (Elwood et al., 1991; Steinber Parthasarathy, Carew, Khoo & Witztum 1989). Burghuber and colleagues ( 1986 ) experimented with involuntary smoking where a group of smokers and nonsmokers sat in a room 20 minutes after cigarettes were smoked. Smokers did not experience changes in their platelets; however, nonsmokers experienced a significant change that made nonsmokers have pl atelet sensitivity similar to smokers (Burghuber et al., 1986). Individuals who already suffer from heart disease are at an extremely high risk for the progression of the disease if they are around secondhand smoke, even with minimal exposure. The U.S. De partment of Health and Human Services (2006) recommends taking precautions to avoi d exposure to secondhand smoke.

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31 Disparities in Secondhand Smoke Exposure The 1998 Surgeon General Report Tobacco Use a mong U.S. Racial/Ethnic Minority Groups r eports differen ces in tobacco use among racial/ethnic minority groups. The report states that African American and Southeast Asian men frequently use tobacco products, whereas Asian American and Hispanic women use tobacco least frequently (USDHHS 1998). This research wi ll collect data from public parks in many different areas where race, socio economic status ( SES ) and occupation may affect the amount of smoking found. There are no known disparities between races and ethnic groups in susceptibility to addiction to nico tine, however the tobacco industry often targets specific racial groups, which creates disparities ( USDHHS, 1998). As the rates of tobacco use in non Hispanic white s decline d the to bacco industry targeted African Americans in order to create positive rela tionships through several means Tobacco companies are donating money to minority education programs, sponsoring cultural events, initiating scholarship programs for minorities and using extreme advertising and merchandising to this racial target (USDHHS 1998). The tobacco industry targets African Americans with specific brands of cigarettes, mos tly menthol flavored brands (USDHHS 1998). African Americans had the highest rate of secondhand smoke e xposure in 2007 2008 at 55.9% (Kaufmann et al 2010; Pirkle Bernert, Caudill, Sosnoff & Pechacek, 2006). This may be a reason as to why African Americans experience the worst health effects due to smoking and secondhand smoke, experiencing twice as high rates of disease than white men and women (USDHHS 1998). N on Hispanic whites were exposed to 40.1% of secondhand smoke while Mexican Americans had a 28.5% exposure rate ( Kaufmann et al. 2010; Pirkle, Bernert, Caudill, Sosnoff & Pechacek, 2006).

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32 There is no single factor influencing different racial or ethnic gr oups tobacco use. S everal factors that influence tobacco use include socio economic status of an individual, particular cultural characteristic of an individual, stress, advertising to specific racial groups and effective tobacco control initiatives (USDH HS 1998). Current research shows that low socio economic status is the greatest predictor of tobacco use (Tobacco free Maine, 2008; Anderson, Oto Kent, Porter, Brown, Quirk & Johnson, 2004). Kaufmann and colleagues declared that secondhand smoke exposu re is higher for low income individuals. Kaufmann and colleagues (2010) reported that 60.5% of people under the poverty line in the US were exposed to secondha nd smoke between 2007 and 2008. King and colleagues (2011) researched current smoking rates among adults utilizing the National Health Interview surveys and the 2010 Behavioral Risk Factor Surveillance survey The survey is administered to a nationally representative random probability sample of adults older than 18. Current cigarette smo kers were de fined in the survey as someone who had smoked more than 100 cigarettes in their lifetime and reported smoking every day or some days The research suggests t hat adults who live below the poverty level used almost double the tobacco products than adults who live at or above the pover ty level ( King, Dube, Kaufmann, Shaw & Pechacek, 2011 ). Johnson and Wang (1996) foun d that children in low income households with parental smokers reported a poor diet quality compared to low income households without smoker s Singh, Siahpush and Kogan (2007) published a study revealing that children from lower socioeconomic backgrounds had up to 10.6 times higher chances to be exposed to secondhand smoke than children from higher socioeconomic

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33 backgrounds. Low income individ uals are also at a higher risk for smoking as well as secondhand smoke exposure (Anderson, Oto Kent, Porter, Brown, Quirk & Johnson, 2004; Adhik i ari et al. 2008). Although occupational disparities regarding exposure to environmental tobacco smoke have d ecreased, there are still cases of inequality despite having laws that protect nonsmokers from exposure in enclosed workplaces. Arheart and colleagues (2008) found that construction workers, blue collar workers, and service workers still experience high le vels of environmental tobacco smoke despite limiting their exposure to secondhand smoke. Other researchers found that food and bar service workers are at high risk of secondhand smoke exposure since several bars and restaurants are still exempt from many s tate and municipality laws that prohibit indoor smoking (Shopland, Anderson, Burns & Gerlach 2004; Siegel, 1993; Siegel, 2003) Siegel (1999; 2003) alleys, billiard halls, be tting establishments, and bingo parlors) in which an employee may inhale secondhand smoke equivalent to smoking 16 cigarettes during an 8 hour shift. Economic Costs and Benefits of S econdhand Smoke Tobacco companies are one of the most profitable corporat ions within the United States, with approximately 45 billion dollars spent annually on tobacco by U.S. residents (BBC News, 1999). In the United States, over 120,000 tobacco farms provide more than 450,000 jobs for U.S. citizens (WHO, 1999; WHO 2008). Due to recent laws and tax increases, Florida experiences the largest amount of advertising and promotion of tobacco products, for which the tobacco indu stry spends $930.4 million, a significant part of the $13.36 bi llion spent nationwide (Boone, 2008).

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34 Alth ough tobacco companies provide benefits for workers, the cost for purchasing United States loses $92 billion due to the medical costs of tobacco related deaths, not in cluding the $81 billion spent annually on healthcare for tobacco related illness (WHO, 1999; WHO, 2008). Florida spends an estimated $6.32 billion annually on tobacco health care costs (Florida Charts, 2007; Robert Wood Johnson Foundation [ RWJF ] 2008). De spite the tobacco industry spending $930.4 million in advertising within Florida, Florida only spends $60.2 million on tobacco use prevention (RWJF, 2008). These costs directly affect smokers and nonsmokers in Florida and throughout the United States. Flor ida households pay approximately $582 in state and federal taxes due to smoking related government expenditures (Florida Charts, 2007). Research shows that a decline of tobacco users in the United States is correlated with positive financial and health ben efits (Boonn, 2008; Lindblom, 2008). Laws Regarding Exposure to S econdhand Smoke Laws and policies towards smoke free spaces aim to eliminate, or at least minimize, rates of exposure to secondhand smoke. State and local laws and policies help protect nons mokers from exposure to secondhand smoke, thus reducing any negative health effects related to exposure. As of January 2, 2012 there are a total of 971 municipalities within 39 U.S. state s that have some sort of smoke free law concerning workplaces, restau rants and freestanding bars (ANR, 2012a). Only 493 municipalities within 23 states are 100% smoke free in all thr ee of those locations whereas 3,487 municipalities have laws that are not fully 100% smoke free in those three venues (ANR, 2012b). The Pro Chi ldren Act (PCA), enacted in 1994, prohibits smoking in federally funded facilities that serve children (Pro Children Act, 2001).

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35 Globally, 66 nations have at least one type of 100% smoke free law, where 46 of those nations include both restaurants and bar s within those laws (ANR, 2012c). The Wendell H. Ford Aviation Investment and Reform Act did not go into effect until 2000, making all flights to and from the United States 100% smoke free (ANR, 2005). Florida has 100% workplace and 100% restaurant smoke free laws (American enacted in 1985 to reduce secondhand smoke exposure (FDOH, 2007). Later the act was elaborated upon and passed in 2003 (Florida Statues Chapter 286 P art II) to prohibit smoking within a workplace (S.386.204, F.S.). Laws other than the FCIAA are only voluntary due to the preemptive clause within the FCIAA that states that no locality has the authority to enact any law more stringent than the state laws (FDOH, 2007a). Therefore, the posted signage use to discourage sm oking behavior within this study is merely a request, not a n enforceable law or city ordinance. Outdoor smoking bans within the United States have increased from 30 bans in 1999 to at least 1124 bans in 2007 (Koch, 2007). As of January 2012, there are 590 municipalities nationwide with smoke free park laws (ANR, 2012d). Two of these municipalities are within Florida, which means they are disregarding the preemptive clause within the FCIAA. I n addition to reducing secondhand smoke exposure to nonsmokers, research has (USDHHS, 2006). Smoke consumption and to in USDHHS, 2000,

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36 p16) These laws also decre ase the amount of children who start smoking and increase the number of successful quitting attempts by current smokers (TFK, 2010). Current Literature Review The prevalence of outdoor smoking bans is increasing in recent years, however little research has been conducted on the ef fectiveness of these bans. C ities such as New York and Traverse City in Northern Michigan are trying to ban tobacco in all outdoor parks (Scheck & Co lvin, 2011; McCray, 2012). Several studies have found indoor smoking bans to be effective (Skeer, Land, Cheng & Siegel, 2004; Weber Bagwell, Fielding, et al., 2003; Lee Moore & Martin 2003). However, due to indoor air act laws to back up the bans ther e is enforcement and consequences if the laws are broken. Central Park is subject to a $ 50 fine (Hanisco, 2011) Therefore, outdoor smoking bans that lack enforcement and punishment must be examined to dete rmine whether smokers comply with the ban. Many college campuses are now creating policies to be smoke free, or at least designating smoking sections around campus (Harris, Stearns, Kovach & Harrar, 2009). College campuses are some of the first outdoor ar eas that have created policies to become smoke free. Examination of the strategies that change behavior and how these policies affect smoking behaviors are limited (Harris et al., 2009). For example, t he University of Florida is a smoke free campus; howeve r, there are no consequences if someone is caught smoking. Santa Fe College in the same area has smoking sections; however, violations in non smoking areas are enforced and people caught smo king are ticketed. Despite such policies, smoking still occurs on campus although at reduced rates ; therefore, research is needed to test these policies and subsequent behavior change.

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37 Harris and colleagues (2009) used an enforcement package on a college campus in which compliance of the current smoking policy was test ed. The campus policy was that no smoking was allowed within 25 feet of buildings; if someone smoking was within that zone, they are noncompliant with the policy. The enforcement package used four different strategies: 1) moving cigarette receptacles out of the 25 foot smoke free zone; 2) creating ground markings that outline the zones; 3) adding signs about the outdoor smoking ban; and 4) handing out positive reinforcement cards redeemable for a free drink at the student building to compliant smokers and reminder cards to noncompliant smokers. The positive reinforcement cards provided incentive for smokers to move their behavior and the support for the ban. The researchers discovered that the enforcement package was successful in increasing compliance and moving smoking behavior away from no smoking zones (Harris et al., 2009). However, the behavior changes reduced after the removal of the enforcement package although it remained higher than in the control setting. Although this study had a positive change regarding the enforcement of a policy, it ha d several methodological limitations. The four component approach wa s applied as a combination ; therefore, no examination was made of which componen t had the most impact ( or whether certain components did not make an impact at al l) In contrast, t h e following research will examine potential effects of one of the four component approaches : posted signage. Another research study looked at the impact of different forms of tobacco free college campuses (n=19) Lee and colleagues (2011) identified differences for

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38 cigarettes smoked at five main campus building entrances by type of smoking policy. policies in the study included having: n o smoke free policy; designated smoking areas; 100% tobacco free policies with smoking policy signage; and 100% tobacco free policies with recep tacles in no smoking sections One hundred percent tobacco free policie s did not have enforcement of the policy, however most compliance issues were based on norms and peer pressure (Lee et al., 2011). Two of the 100% tobacco free schools had signage at all building entrances and four had signage at some entrances. Five of th e medium policy strength schools (ones with designated smoking and non smoking areas) had signage at all entrances and two had some at some entrances. There were no receptacles in 100% tobacco free policy building entrance areas (for those schools with 100 % tobacco free policies and receptacles however low and medium policy schools had receptacles in building entrance areas. The researchers had volunteer students collect cigarette butts within a 15 feet rad ius of five main building entrances at two different time intervals. The second collection occurred 7 days later with the same volunteers in the same areas. Lee and colleagues (2011) calculated rates of cigarettes smoked each individual day and created a campu s score that was an average of the five buildings in order to run statistical analyses. As policy strength increased, there was a smaller amount of cigarette butts in non smoking areas. Tobacco free campuses (n=6) had the lowest amounts of cigarette butts, which was significant at p< 0.02 compared to colleges with low strength tobacco policies. This shows that only 100% smoke free policies were associated with reduced cigarette butts due to signs that were placed at all or at some

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39 of the building entrances. This newly published research is an important basis for this study and its replication in park amenities. Despite the growing number of tobacco free park policies, there is little known about the attitudes of the public towards these laws (Klein et al., 2 007). Over 70 communities in Minnesota ban or limit tobacco use in parks and recreational grounds, though little is known about public support for these policies. Klein and colleagues (2007) administered surveys to the public and some park officials, findi ng that 70% of respondents favored tobacco free park policies. However, concerns centered on enforcement and compliance issues. Therefore, even though there is some research on attitudes on signs stating there is a smoke free policy, there is a ga p in the research on whether it will cause behavior change. A case study examined how a 12 year old was able to get a city council to adopt a resolution that made city parks smoke free (Henriques, Newton & Marshak 2003). The city council granted the res olution and put up signage indicating that the parks were smoke free. The researchers administered a survey to see what community members thought of the signage; 93% of respondents were in favor of t he new signage. Although there was a great amount of part icipants in favor of the signage that makes the city parks smoke free, it cannot be determined whether the signs had any effect on the frequency of smoking with the parks. A similar study researched the Young Lungs at Play campaign that designed and implem ented smoke free signage into parks (Jacobson et al. 2007). Jacobson and colleagues (2007) state d that the campaign was a success in terms of making antismoking messages more visible to children and

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40 having adults model good health habits as well, though t hey make no mention on the Social pressure by non smokers may aid in compliance; however, Chaloupka and colleagues (2008) in their paper examining enforcement issues for tobacco control policies stated that e nforcement must be used to improve compliance. Lazuras, Eiser and Rodafinos (2009) surveyed college students in Greece regarding non compliance with tobacco control policies such as smoking bans. Participants who were smokers reported that they were more likely to smoke in an area where smoking was prevalent and seemed socially acceptable. In addition, smokers in the study had more negative attitudes towards smoking bans compared to non smokers, meaning that they are less supportive of these bans and are m ore likely to be non compliant (Lazuras et al., 2009). Therefore, it is important to research what will move the smoking behavior of individuals. The following section will discuss signage and behavior change. Signage and Behavior C hange Signs are a behavi oral stimulus that have been deemed effective in treating multiple problems through behavior changes (Jason & Liotta, 1982). The important factor being investigated is that there is no additional enforcement other than the signs themselves. All research co ncerning signage must only rely on signs for behavior change. Since outdoor smoking bans using signage are a newly studied topic, it is important to investigate studies that use signage alone to assess whether they alter human behavior. Due to a limited a mount of research concerning signage and smoking behavior (Harris et al., 2009), research that investigates using posted signage as an impetus to behavior change will also be reviewed.

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41 Dawley and colleagues (1980) studied compliance behavior towards no sm oking signs by employees and patients in a hospital setting. Three baseline data points were collected prior to putting up smoking and nonsmoking sections in the hospital area. The researchers took time samples of 10 minutes for three weeks to determine i f signs alone moved smoking behaviors to a smoking section. The researchers observed that d ividing the areas of smoking and nonsmoking immediately had an effect of decreasing smoking in the nonsmoking section This is a limitation within the study b ecause the baseline data that were collected did not have a separation of smoking and nonsmoking areas, which means signs were not the only variable introduced. Results demonstrated positive compliance among employees and patients for the first week, but the seco nd week the results returned to pre treatment baseline levels (Dawley, Morrison & Carrol, 1980). The researchers stated that employees knew there was no enforcem ent of the policy, so they started smoking again. If employees are smoking in nonsmoking sect ions, then patients will most likely smoke there as wel l because the staff members are. Dawley and colleagues (1981) did another study with posted signage using either negatively or positively worded no smoking signs to determine which would reduce smoki ng the most in a hospital main lobby. The researchers believed that the negatively worded signage would have a greater effect in reducing smoking. Using observational methods, the results showed that both types of signage produced higher compliance rates, although the positively worded signs were more effective. It may be useful to use positive worded signage in order to gain compliance in future studies.

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42 Another study used no smoking signs to decrease smoking in a section of a university cafeteria (Jason & Liotta, 1982). There was a 10 day period where observers created baseline data points of smoking within the targeted area through an observational data methodology The researchers observed individuals who smoked within the target area every day of the w eek for 50 minutes. This was followed by a 16 day period of having no smoking signage posted in the targeted area. Next, a second baseline was established for 5 days (removal of prior signs), followed by 10 days of posted signage and verbal prompting (tell ing a smoker to move or stop the smoking behavior). A third baseline was then established, and then no smoking signage was posted for 8 days while verbal prompting was introduced the last 5 days. Signage alone within this study produced only minimal change s in smoking behavior, however prompting and signage had a greater effect on compliance. A limitation in this study was that they used the same area to test different versions (signs, signs and verbal prompting). This study could have been stronger if the researchers used three randomly assigned university cafeterias where one was a control, one only had signs, and one had signs and verbal prompting. The primary researcher took part in an observational study that occurred prior to conducting the current res earch. Platter, Pokorny and Ryant (2011) observed four zones within a community plaza in the same region in which the parks study was done to observe smoking behaviors. Observations were within specific targeted areas for five minute intervals. The researc hers did two observations during the control (no signage present) and seven observations during the inte rvention (signs were present). After the signs were placed throughout the community plaza, smoking behavior showed no stable

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43 trends and there were no no ticeable chances in observed smoking rates. However, mid day was discovered as the high time of park patrons and smoking behaviors. However there is a large homeless population that frequently attends the plaza during this period Ford and Torok (2008) s tudied whether posted signage increased or decreased physical activity on a college campus. This study is part of several studies that have evaluated signage and its effectiveness to change behavior of individuals to take the stairs (Ford & Torok, 2008; An derson, Franckowiak, Snyder, Bartlett & Fontaine, 1998; Boen et al., 2010; Nomura et al., 2009). This study utilized three phases: baseline, intervention, and removal of intervention. During the intervention period, there was a significant increase in sta ir use that was maintained post intervention. The limitation in this research is that they only investigated post intervention data for one week, which means that the long term effectiveness of the signs is unknown. Another study investigated the effectiv eness of posted signage for increasing stair use in a train station (Nomura et al., 2009). The researchers used a 2 week baseline and a 4 week intervention but did not do any post intervention data. The study was also published in a newspaper article in or der to see if that had any effect on influencing the use of stairs due to the signs. The signage was effective in changing behavior, though the published article had no known effect. Boen and colleagues (2010) also tested the impact of signage to increase stair usage in a train station. However, this study had a baseline, first intervention, post intervention and second intervention measurements. The results found significant increases in stair use during and after intervention. The researchers also cite th p. 183 ).

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44 The Health Belief Model The Health Belief Model is a widely utilized theory and a conceptual framework that is applied to multiple research studies concer ning health behavior change (Becker & Rosenstock, 1984). Irwin Rosenstock, Godfrey Hochbaum and Stephen Kegels first developed the Health Belief Model utilizing free health services (Burns, 1992; Mikhail, 1981). It was later further developed by Irwin Rosenstock in order to understand usage of health services and was later expande d by Becker (Rosenstock, 1966 ). It is often used to explain a variety of health behaviors such as sexual risk behaviors and HIV, vaccination, screening, tobacco use, clinic utilization and drunk driving (Janz & Becker, 1984; Brown, DiClemente & Reynolds, 1991 ; Bandura, 1989; Rosenstock, Strecher & Becker, 1994). The Health Belief Model is frequently used to explain and predict hea lth behaviors in diverse populations using different constructs that help explain health behavior. The Health Belief Model encompasses s ix components to explain health behavior: perceived susceptibility, perceived benefits, perceived barriers, perceived se riousness /severity cues to action, and self efficacy. Each co nstruct alone or in combination, is able to predict health behavior (Hayden, 2 009). Many of the components of the health belief model will be discussed in this research such as perceived susce ptibility, perceived severity, perceived benefits, perceived barriers, and cues to action Each component is important to study in terms of changing a health behavior. The following table shows examples of each construct within the health belief model in r elation to smoking in park amenities

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45 T able 2 1 : The health belief m odel and s moking in park amenities Construct Perceived susceptibility: Smokers may or may not believe that adults or children in park are susceptible to negative health effect s associated with secondhand smoke. Perceived severity: Smoking in a park with recommended no smoking areas may have high severity due to socially related consequences I ndividua ls may not have a high severity because there is no law go verning smoking near signs. Perceived benefits: Able to relieve a sudden urge or need to smoke. Perceived barriers: Addiction, social norms and barriers ( nonsmokers approaching smoker in park ), habit of smoking outsi de. Cues to action : Posted signage in park amenities. Self efficacy: Belief in the ability to not smoke for short term in park amenity. The researcher utilized the theoretical construct perceived s usceptibility. The signs posted in park amenities within this study ask smoking park patrons to refrain from smoking due to the health and safety consequences associated with secondhand smoke. Smokers may or may not believe that adults or children in park are susceptible to negative health effects associated with secondhand smoke. However, what is written on the signs demonstrate what a smoker may believe the perceived susceptibility of their action is on other park patrons. This research also used the con struct perceived seriousness. This construct is an consequences associated with the posted signage. Signs are seeking to change normative behaviors of park patrons in smoking by changing the environment. or lack thereof, a sign would create if they smok ed in this area. Since these signs may

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46 help change park norms around smoking, a smoker may feel uneasy about smoking in a park amenity with smoke free signage posted. This research looked at the perceived benefits and barriers of smoking in a park amenity that has posted smoke free zone signs. The benefit of smoking in park amenities for a smoker is that they are able to relieve their need, or craving, to smoke. There are several barriers for a park patron who is a smoker. Smokers are addicted biologically to the nicotine within cigarettes and to the social addition due to smoking habits and social interactions Addiction may make it difficult for these park patrons not to smoke. Park patrons who are smokers may also have a habit of smoking outdoors, which may make it d ifficult for them not to smoke in a park amenity. This research utilized the construct cues to action. Research has shown that cues to action are an important part of triggering action in people and can influence behavior of individuals (Hayde n, 2009). The construct addresses posted signage, an external cue that motivates behavior regarding smoking in public parks. The sign s are a cue to action that may motivate people to move their smoking behaviors outside of the targeted park amenities. The posted signage may be a cue that also influences nonsmokers to tell smokers to move o r stop their smoking behaviors within park amenities.

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47 CHAPTER 3 METHODS Purpose The purpose of this study wa s to assess the impact of posted Smoke Free Zone signage on park patrons smoking behavior among different amenities (playgrounds, restrooms, and picnic pavilions) in public parks in Gaines ville, Florida. This study aim ed to discover whether posted anti smoking signage that is not backed by law in public parks woul smoking behaviors in different amenities. This is a first study of its kind to address possible effects of smoke free zone signage that have no ordinance or law attached to them. Design This study used a time series quasi exp erimental design to determine how posted signage in parks affects behavioral smoking change. Quasi experimental designs replicate the features of a classic experimental design except that such design lacks a random assignment to a control and experimental group (Gree no, 2002). Time series is a research design where the same variables are measured at different times (Jupp, 2006). A time series quasi experimental design was used to establish a baseline measure in order to discover trends and describe changes throughout the study. It also help ed determine whether there are any treatment effects due to the presence of posted signage. The time series design also allow ed the researcher to collect data in park amenities at the same time each week on the scheduled d ata collection day. The four parks used in this research had a control observation period (no signage) of 6 weeks, then an intervention observation period (posted signage) of 6 weeks. The researcher had to collect data for 6 weeks in order to establish a s teady baseline. Once an

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48 established baseline was achieved, the intervention (signage) was introduced into the four parks and their amenities. Sample Selection Population The theoretical population for this study is all recreational parks within Northern F lorida. The researcher does not have access to the entire theoretical population. Therefore, the researcher used an accessible population of parks within the City of Gainesville, Florida. The accessible population represents the theoretical population in t erms of parks because they are similar to other recreational parks within Northern Florida. Sample This study use d a non probability sample, known as criteria sampling. Criteria samples are commonly used in quasi experiments (Swisher, 2012). Criteria sam ples select the participant due to specific characteristics such as criteria, homogeneousness, and matched (Swisher, 2012). The research er want ed each park to be as similar as possible in terms of amenities. Therefore, there was a need to gain information about the parks through pre observations before selecting the sample. The sampling frame for this project wa s a list of 39 parks within the City of Gainesville, Florida received by Steven R. Philips, the Director of Director of Parks, Recreation and Cultur al Affairs Department for the City of Gainesville. Sampling frames strengthen non probability samples because you can use the frame to select sample subjects (Swisher, 2012). The researcher originally had eight matched parks based on amenities and size bu t signage was inserted into the four intervention parks early, therefore eliminating the establishment of a baseline in the intervention parks Despite the parks having the

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49 necessary amenities, it was discovered that foot traffic, residential area, SES of park patrons all accounted for types of use of the parks that makes it difficult to match parks based on amenities. Therefore, the researcher only used the four control parks and did the intervention after establishing a baseline data trend Despite the ch ange in design, the current design negates threats to validity due to the parks serving as their own control over time. There was no need to control for foot traffic in each park because it is assumed that it stayed constant due to within subject design. Park patrons are users of a park who may or may not smoke tobacco. There was no social interaction between the research er and park patron, nor were they the unit of analysis or measurement; however, data w ere collected through the gathering of cigarette bu tts found in the targeted amenities within all four parks. The quantity of cigarette butts, the dependent variable in this research, cannot be linked with specific individuals. IRB approval was receive d and can be seen in Appendix D. Collection Zones The c ollection zones were the same for each park, with minor adjustments due to d Dr. Steven unpublished research ( Pokorny, 2012 ). The collection zone procedure collected cigarette butts within 25 feet of established buildings in order to examine the current tobacco policy on a college campus (Pokorny, 2012). This study methodology also replicates Lee and (2011) research on cigarette butts near building entranc es on college campus that have smoke free policies. The researchers looked at five different campus buildings to better capture differences of smoking patterns in different areas. This is similar to the current study methodology, as the researcher is looki ng at three different amenities to better capture differences of smoking patterns in

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50 different park amenities. The researchers used a 15 foot radius from the largest main entrance of the buildings in which volunteer student aids collected cigarette butts a nd recorded the n umber that were collected (Lee et al., 2011). Lee and colleagues (2011) had volunteers collect cigarette butts during the pilot testing and the protocol implementation. During the pilot testing volunteers cleaned up cigarette butts in the 15 foot radius from building entrances. Then the same volunteers returned 7 days later to cleanup a second time and to count the cigarette butts. The current methodology differs from the Lee and colleagues (2011) study concerning the frequency of data coll ection. The current study establishes a baseline measure through six weeks of data collection at each park amenity versus a one time data collection at each building amenity as A baseline measure was used in t he current research because it allows the researcher to look for trends regarding the dependent variable before the treatment is implemented. Lee and colleagues (2011) included the point that collected cigarette butts do not capture the range of s moking b ehaviors in these areas in their work ; however, cigarette butts are a tangible way to access data on smoking behavior in outdoor areas, other than more costly observational methods Moreover, secondhand smoke exposure of non smokers in a studied outdoor ar ea is not quantified by collecting cigarette butts (Lee et al., 2011) A lso mentioned by Lee and colleagues (2011) are limitations similar to this stud y They were unable to control for cleanup of cigarette butts in outdoor facilities by ground staff and t hat this could bias results towards the null hypothesis that signage, policy, or other intervention could accompany a reduction in smoking behavior as indicated by number of cigarette butts collected at a given time The researchers also

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51 did not finish col lecting cigarette butts from campuses in the same period There may be variability in measuring the 15 foot areas because each building was different (similar to amenities being different in parks). The study also had a small sample size and the results ar e limited to its geographic location of community colleges. The researchers recommended replication of the study to expand the results to other campus settings. Other st udies concerning litter research use a similar methodology as well where they pick up and count evidences of human littering behavior (Crump, Nunes & Crossman, 1977; Clark, Burgess, & Hendee, 1972). K eep A merica B eautiful (2009) examin ed litter and littering in America, which used a similar methodology involving litter in roadways, includ ing collecting and counting cigarette butts. The study explored the composition of litter including its volume, locations found, and cost to the community ( Keep America Beautiful [KAB] 2009 ). Furthermore, the study explored the frequency of littering, var iables that contribute to littering and the efficiency of different methods to reduce litter. Roadways were the focal point in this research, which accounts for 3.8 million miles in the United States (KAB, 2009). In order to estimate litter in roadways, t he researchers would select random samples of 240 roadway segments. The researchers had multiple samples so they selected 300 by 15 foot areas where the researcher made observations of densely litter ed areas ( 4 or more inches of trash in a given area) The researchers areas and f ollowing the count, they photographed sample site s and rated them from 1 to 5 with one signifying no litter and five signifying extremely littered ( KAB 2009). The researchers used the perc entage of litter to statistically weight and estimate frequency

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52 of litter across all roadways. Tobacco products made up 38% of the trash in extremely littered areas In th e current study, t he collection zones focused on the amenities chosen in the initial observation period. Different amenities were chosen in order to assess differences in smoking patterns within and around different amenities. The collection zone for cigarette butts extended from zero to 25 feet from pavilions, playgrounds and restrooms. The collection area was where smoking is not recommended, which is 0 to 25 feet from each amenity To estimate square footage of these areas, a 25 foot measurer was used to mark the 25 foot violation zone around each specified amenity or sign. Cones were u sed to mark the boundary lines around each selected area. Only cigarette butts within 25 feet of signs posted in and around amenities were counted. During each week throughout data collection, the boundary lines between the zones were clearly marked with r ope and cones. Data were collected on the same day of every week at approximately the same time of day unless weather prohibited researchers from collecting at the same time. Procedure Through collaborating with Steven R. Phillips, the Director of Parks, Recreation and Cultural Affairs Department for the City of Gainesville, a l ist of parks within Gainesville, Florida was received. This project researched and utilized four different parks from a sampling frame of thirty nine Gainesville parks. A matrix was created from the sampling frame which listed parks based on amenities such as land acres, special facilities, ball fields, nature trails, exercise/jog trails, paved trails, unpaved trails, basketball (# of goals), picnic areas, playgrounds, racquet ball c ourts, rest rooms, tennis courts, skate parks, and board walks ( See Appendix C )

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53 Parks were chosen for the study due to having the same type of amenities. In order to assess the similarities of the suggested parks, each park was pre observed to visually c onfirm if amenities and parks were similar. The initial observation stage also allowed the researcher to discover the amenities in need of posted signage for possible treatment. This project used a quasi experimental design for the four parks. The four pa rks did not receive any treatment for the first six weeks in which a baseline in the rate of cigarette butts collected in each park stabilized Then the four parks had Smoke Free Zone signage posted near selected amenities, where placement was established in the pre observation stage. Cigarette butts were collected in the parks before signage was placed in order to compare cigarette butts before and after the parks had posted signage. After approximately six weeks of data collection, signs were posted into the parks. Data collection with the signs took place for an additional six weeks when a stable trend emerged as it did in six weeks of data collection prior to signage being placed Cigarette butts were collected within a twenty five foot parameter surr ounding all selected amenities within all four parks. Each cigarette butt found in all four parks within the twenty five foot perimeter around the amenities was counted as evidence of smoking in the park. The primary researcher with consultation with the s econdary researcher and Co Chair determined sign placement within selected amenities. The signs were located at point of decision areas, such as around bathroom doors, entrances to amenities, and

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54 inside picnic pavilions. Each park received different amount s of signage depending on amenity size and number of entrances into the amenity. Data were collected by the primary researcher secondary researcher and trained volunteers. Volunteers were trained prior to the start of data collection. The researcher too k volunteers to a park that was not included in the study and demonstrated how to properly measure amenity areas and collect cigarette butts Volunteers used plastic gloves and large sandwich bags to collect cigarette butts. After the demonstration, volunt eers were able to practice measuring amenity areas and collect ing cigarettes properly. Volunteers were also able to ask questions during this time regarding the research. When the researcher or a trained volunteer was questioned about what they were doing, they briefly explained that they were collecting data. The dependent variable is the amount of cigarette butts found (lower amount, same amount, or higher amount). The independent variable in this thesis is the posted signage. Data Collection The data co llection procedure involved the collection of cigarette butts in the selected amenity areas in the four parks. The amenities were selected due to high volume use reviewed during an i nitial observation of the parks. There was a twenty five foot parameter us ed around each amenity for consistency in collection purposes. In the week prior to the first baseline assessment, each park was cleared of all cigarettes within the twenty five foot parameter of the selected amenities. This gave a clean, fresh start in or der to establish a data trend in each of the four parks. Data collection started in week one. For the subsequent six weeks, the researcher collected, counted (twice) recorded and properly disposed of cigarettes within the twenty five foot parameter of the

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55 targeted amenities in each of the four parks. Cigarette butts count as evidence of smoking behavior of a park patron. Sign Development The primary researcher in partnership with co chair committee member Dr. Steven Pokorny from Alachua County Health Depa rtment and Tobacco Free Alachua, and Steven R. Philips, the Director of Parks, Recreation and Cultural affairs for the City of Gainesville developed the no smoking signs for this study All prior no smoking signage was researched for wording examples ( Exam ples of signage can be found in Appendix B .) Dawley and colleagues (1981) found that positively worded no smoking signs reduced smoking more than negatively worded no smoking signs. After numerous trials, h and Safety of our Kids Please Help us Keep This Park Smoke Free as Requested by the Gainesv i lle City Commission. Table A 3 shows the amount of signs per amenity in each park. Data Analysis Nonparametric method s were used to assess mean differ ences in ter ms of rank signed rank test). because it does not depend upon normally distributed data. Comparisons we re made between the means over the six weeks cigarette butts were collected when no signage was present in parks as compared to mean numbers of cigarette butts collected in the following six weeks in which signage was posted. The cigarette butts in amenities of each park before and after signage were the point of comparison. Th e researcher tested whether signage had any effect in reducing the amount of cigarette butts by comparing means in cigarette butts collected during the baseline period versus means during intervention period. The r esearcher also tested which

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56 amenity had po ssibly the greatest change in means of cigarette butts collected between baseline data collection and intervention data collection.

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57 CHAPTER 4 RESULTS Over the twelve weeks of data collection 2,692 cigarette butts were collected in four public parks (n=4) Of the 2 692 cigarette butts, 1 648 were collected during the baseline period and 1008 were collected during the intervention period. The researcher collected 64.78 % of cigarette butts in the picnic pavilion amenities (n=4) ; 28. 49 % of cigarette butts wer e collected from playgrounds (n=4); and 6.7 2 % of cigarette butts were collected from restrooms (n=2). One observation day was skipped for Greentree p ark during week 4 but the researchers split the data from week 5 in half to fill in week 4 because it was double the normal amount. Due to missing data because of weather, days without data were filled in with the average of all prior data points. This method mean substitution, is common in research where imputation replacing the missing values with an estima te, such as the mean of the observed values for the variable (Grace Martin, 2001). Greentree and Roper parks during Week 6 did not have any data so the researcher took the mean of weeks 1 5 to fil l in the average for the missing data. This also happened i n Week 7 for Northeast and Possum parks and week 12 for Greentree and Roper parks Tables A1 and A2 show the collected data. Table 4 1 : P ark s and amenit ies Park Amenity Northeast Playground Picnic Pavilion Restroom Possum Playground Picnic Pavilion G reentree Playground Picnic Pavilion Restroom Roper Playground Picnic Pavilion

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58 Northeast park and Greentree park were the only two parks with a restroom a menities Every park had at least a playground amenity and a picnic pavilion amenity. Table 4 2 : Cigarette butts collected by amenity Amenity Frequency Percent Playground 767 .00 28.49 Picnic Pavilion 1744 .00 64.78 Restroom 181 .00 6.72 Overall, 2, 692 cigarette butts were collected in 10 amenities within 4 different parks. The majority of ci garette butts were found in picnic pavilions, followed by playgrounds and lastly restrooms. Table 4 3 : Cigarette butts collected by amenity during baseline Amenity Frequency Percent Playground 481.40 29.21 Picnic Pavilion 1108 .00 67.23 Restroom 9 4.60 5.74 This table (4 3) describes the number of c igarette butts collected during the baseline data collection The percentages here are the amenity frequency out of 1,648. Table 4 4: C igarette butts collected by amenity after signage placement This table (4 4) describes the number of cigarette butts collected in the intervention period when signage was placed. The percentages here reflect the a menity frequency out of 1,008. The r esearcher wanted to test whether the number of cigarette butts collected would change once signage was placed in park amenities. As covered in the hypotheses, an expectation was that the amount of cigarette butts collected would decline after signage was placed in amenities Due to the number of Ameni ty Frequency Percent Playground 285.60 28.33 Picnic Pavilion 636 .00 63.09 Restroom 86.40 8.57

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59 parks and amenities being low, the data were not normally distributed Therefore, the researcher conducted several nonparametric Wilcoxon signed rank tests to compare mean numbers of cigarette butts collected in each park amenity before and after signage was placed (averaged over 6 times per week before and 6 times per week after Nonparametric tests are used when the sample is not normally distributed (Lowry, 2011). T he Wilcoxon signed rank test is similar to the paired sample t test, but for data that are not normally distributed (Wilcoxon, 1945). The following tables show Wilcoxon test results for overall amenities in parks and for each amenity individually. Table 4 5 : Ranks comparing baseline data collection with signage data collection over all 10 amenities in parks (4). N Mean Rank Sum of Ranks Post Pre Negative Ranks 7a 7.00 49.00 Positive Ranks 3b 2.00 6.00 Ties 0c Total 10 Table 4 5 provides results on the comparison of cigarette butts in parks and their amenities before (pre) and after (post) introduction of signage. Seven amenities had a lower amount of cigarette butts after signage was placed However, three amenities had a higher amount of cigarette butts after signs were placed None of the amenities experienced zero change in the cigarette butt amounts. Table 4 6 : Test s tatistic of overall a menities *p<0.05 Post Pre Z 2.191b Asymp Sig (2 tailed) .028 The Wilcoxon signed rank test i ndicated that the introduction of signage was associated with a statistically significant change in cigarette butts collected at baseline and signage conditions in ameni ties within parks. The p value wa s statistically significant at .028.

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60 The following tw o box plots show the average number of cigarette butts found during the baseline data collection period and the during the collection period after signage was placed. Figure 4 1: Box plots of average cigarette butts found during the baseline data colle ction period at different park s. Note that the center bold line represents the median rate, the box represents the 25 th through the 75 th percentiles and the whiskers show the range of rates. Figure 4 2: Box plots of average cigarette butts found during data collection period after signage was placed at different park s and amenities Note that the center bold line represents the median rate, the box represents the 25 th through the 75 th percentiles and the whiskers show the range of rates.

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61 The researcher also wanted to test whether type of amenity was related to differences in reduction of number of cigarette butts from baseline to signage placement conditions. A Wilcoxon signed rank test was used to analyze each park amenity. Table 4 7 : Ranks of p icnic pavilion a menity N Mean Rank Sum of Ranks Post Pre Negative Ranks 3a 3.00 9.00 Positive Ranks 1b 1.00 1 .00 Ties 0c Total 4 Table 4 7 provides data on the comparison of cigarette butts in the picnic pavilion amenities before (pre) and after ( post) introduction of signage. Three of the four picnic pavilion amenities had a lower amount of cigarette butts after the treatment. One picnic pavilion amenit y had a higher amount of cigarette butts after signs were placed None of the picnic pavilion am enities showed zero change in the average cigarette butt amounts collected across baseline and signage conditions. Table 4 8 : Test s tatistic of picnic p avilion a menity Post Pre Z 1.461b Asymp Sig (2 tailed) .144 The Wilcoxon signed rank test in d icate d that the introduction of signage in picnic pavilion amenities was not associated with a statistically significant decrease in cigarette butts collected between baseline and signage collection. Table 4 9 : Ranks of playground a menity N Mean Rank Sum of R anks Post Pre Negative Ranks 3a 3.00 9.00 Positive Ranks 1b 1.00 1 .00 Ties 0c Total 4

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62 Table 4 9 provides data on the comparison of cigarette butts in the playground amenities before (pre) and after (post) introduction of signage. Three of the four playground amenities had a lower amount of cigarette butts collected after signage was introduced. O ne of the playground amenities had a higher average amount of cigarette butts after sign age was introduced None of the playground amenities experience d zero change in the average number of cigarette butt collected at baseline and signage conditions Table 4 1 0 : Test statistic of playground a menity Post Pre Z 1.461b Asymp Sig (2 tailed) .144 The Wilcoxon signed rank test indicated that the introduc tion of signage in playground amenities was not associated with a statistically signif icant decrease in cigarette butts. Table 4 1 1 : Ranks of r estroom a menity N Mean Rank Sum of Ranks Post Pre Negative Ranks 1a 2.00 2.00 Positive Ranks 1b 1.00 1 .00 Ties 0c Total 2 Table 4 11 provides data on the comparison of the restroom amenities before (pre) and after (post) introduction of signage. One of the restroom amenities had a lower amount of cigarette butts after signage was introduced However, on e of the restroom amenities had a higher average amount of cigarette butts collected after signs were introduced None of the restroom amenities experienced zero change in the cigarette butt amounts collected across baseline and signage conditions. Table 4 1 2 : Test s tatistic of r estroom a menity Post Pre Z .447b Asymp Sig (2 tailed) .655

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63 The Wilcoxon signed rank test showed that the introduction of signage in restroom amenities was not associated with a statistically significant decrease in cigarette bu tts collected at baseline and signage conditions. Figure 4 3: Box plots of average cigarette butts during the control data collection period at different amenities. Note that the center bold line represents the median rate, the box represents the 25 th through the 75 th percentiles and the whiskers show the range of rates. Figure 4 4: Box plots of average cigarette butts during the intervention data collection period at different amenities. Note that the center bold line represents the median rate, the box represents the 25 th through the 75 th percentiles and the whiskers show the range of rates.

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64 The researcher also ran a Wilcoxon signed rank test for each individual park (with either 2 or 3 amenities) to test for a statistical difference between baselin e and signage cigarette butt collection times. Table 4 1 3 : Ranks of Northeast park N Mean Rank Sum of Ranks Post Pre Negative Ranks 3 a 2.00 6 .00 Positive Ranks 0 b 0 .00 0 .00 Ties 0c Total 3 The ranks table provides data on the comparison of the amenities within Northeast park before (pre) and after (post) introduction of signage. All of the amenities in Northeast park had a lower amount of cigarette butts after signage was introduced None of the amenities experienced zero or positive change in the cigarette butt amounts collected between baseline and signage conditions. Table 4 1 4 : Test statistic of Northeast park Post Pre Z 1. 604b Asymp Sig (2 tailed) .109 The Wilcoxon signed rank test indicated that the introduction of signage in Nort heast park was not associated with a statistically significant change in amount of cigarette butts collected at baseline and signage conditions. Table 4 1 5 : Ranks of Possum park N Mean Rank Sum of Ranks Post Pre Negative Ranks 2 a 1 5 0 3 .00 Positive Ra nks 0 b 0 .00 0 .00 Ties 0c Total 2 Table 4 15 provides data on the comparison of the amenities within Possum park before (pre) and after (post) introduction of signage. Both of the amenities with in

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65 Possum park had a lower amount of cigarette butts c ollected after the signage was introduced. None of the amenities experienced zero or positive change in the average number of cigarette butts collected be tween baseline and signage conditions. Table 4 1 6 : Test statistic of Possum park Post Pre Z 1. 342b Asymp Sig (2 tailed) .180 The Wilcoxon signed rank test indicated that the introduction of signage in Possum p ark was not associated with a statistically significant change in average number of cigarette butts collected between baseline and signage cond itions. Table 4 17 : Ranks of Greentree park N Mean Rank Sum of Ranks Post Pre Negative Ranks 1a 3 .00 3 .00 Positive Ranks 2 b 1.5 0 3 .00 Ties 0c Total 2 Table 4 17 provides data on the comparison of the amenities in Greentree park before (pre) and after (post) introduction of signage. One of the amenities had a lower amount of cigarette butts after the treatment. However, two of the amenities in Greentree park had a higher amount of cigarette butts after the treatment of signs. None of the rest room amenities experienced zero change in the number of cigarette butts collected between baseline and signage conditions. Table 4 1 8 : Test statistic of Greentree park Post Pre Z .000b Asymp Sig (2 tailed) 1.000

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66 The Wilcoxon signed rank test indicated that the introduction of signage in Greentree park was not associated with a statistically significant change in average number of cigarette butts collected between baseline and signage conditions. Table 4 19 : Ranks of Roper park N Mean Rank Sum of Ran ks Post Pre Negative Ranks 1a 2.00 2.00 Positive Ranks 1b 1.00 1 .00 Ties 0c Total 2 The ranks table provides data on the comparison of the amenities in Roper park before (pre) and after (post) introduction of signage. One of the amenities had a lower amount of cigarette butts after the treatment. However, one of the amenities had a higher amount of cigarette butts after the treatment of signs. N either of the amenities had zero change in the average number of cigarette butts collected between bas eline and signage condition. Table 4 20 : Test statistic of Roper park Post Pre Z 0.447b Asymp Sig (2 tailed) .655 The Wilcoxon signed rank test indicated that the introduction of signage in Roper park was not associated with a statistically signific ant change in average number of cigarette butts collected between baseline and signage conditions.

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67 CHAPTER 5 DISCUSSION The results section tested the main hypotheses from this research. The results indicate evidence to support the first hypothes i s. In the following sections, I will discuss the main results and their possible meanings. I will also discuss other findings in this research that were discovered. This section will also address implications of this research, limitations and suggestions for fut ure research. Main Findings The first alternative hypothesis noted in this research was that the presence of signs would have an effect on smoking in parks compared to the control. The re searcher can reject the null hypothesis, as there was a difference i n cigarette butts between the control and intervention periods for all parks and amenities Due to the data not being normally distributed, a Wilcoxon signed rank test was computed, which indicate d that the introduction of signage was associated with a sta tistically significant change in cigarette butts found in amenities within parks. The p value wa s statistically significant at .028. Overall, the introduction of smoke free zone signage was associated with a decreased number of cigarette butts found in th e four parks The mean of cigarette butts found in all parks was 28.07 in the control (no signage) period and decreased to 16.80 during the intervention (signage) period. Other than possible third variables (to be discussed in limitation section), one int erpretation may be that i ndividuals occupying these amenities may have had a higher perceived seriousness of the consequences to smoking, which led them to move their smoking behavior away from non smoking sign areas. The minimal decrease in cigarette butt s found by restrooms may be due to

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68 changing social norms about smoking and the fewer number of park patrons in restroom area s. As the least occupi ed space of the three amenities, restrooms areas may pose lesser chance for non smoking patrons to point out s ignage and ask smokers to stop. In other words, there may have been a low er perceived seriousness for smokers in restrooms to experience social norm pressure, as compared to playgrounds and picnic pavilions frequented by more patrons Although the interve ntion (signage) was associated with a significant decreas e of cigarette butts found within park amenities, the amount of variability across amenities was unexpected. This may be explained by the differences in the physical layouts of the parks and their am enity areas. It may also be explained due to the amount of usage of specific amenities. For example, in Northeast Park, in data collection in both baseline and when signage was introduced, there were three times as many cigarette butts in the playground th an the restroom, an d three times as many cigarette butts in the picnic pavilion than the playground. This gave the park a large variability from the mean. In terms of amenities, the amount of cigarette butts found in playgrounds ranged from three to 36, pi cnic pavilions ranged from nine to 111, and in restrooms from one to 17. This resulted in large standard deviation s Surprisingly there was no confirmation of t he second alternative hypothesis dependent upon rejection of the first null hypothesis, which was supported by a statistically significant reduction in cigarette butts found from baseline to when signs we re placed in park amenities The researcher wa s unable to reject the null in the second hypothesis that playground amenities would experience a g reater change or reduction in number of cigarette butts found than for other park amenities The

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69 playground amenity p value was not statistically significant. T he Wilcoxon signed rank test showed that both playgrounds and picnic pavilions experienced three out of four amenities as decreasing in cigarette butts, however they were not statistically significant. In this study, point of decision prompts were signs encouraging smoke free zones in parks and were drawn out to be placed where the researcher believ ed were high intervention zones (Solar et al., 2010). The researcher believes that s ign placement may influence the decrease in cigarette butts in amenities. The researcher hypothesizes that if signage within and around the playground amenity was placed in point of decision areas that the researcher originally decided, then the playground amenity would have experienced a much greater decline in cigarette butts than the other two amenities. Despite the researcher mapping out point of decision placement for e ach sign in every amenity, some of the signs were not placed in the correct spots. In addition signs were not placed within the playground as they were in the picnic pavilions but within the 25 feet perimeter surrounding the amenity. Several volunteers in the study stated that signage was much less obvious in the playground amenities compared to the picnic pavilion amenities. Other Findings The researcher investigated each neighb orhood the four parks were in regarding median income to see if there was a link between median income and the decrease in cigarette butts collected after signs were posted in park amenities I nformation about each individual park neighborhood, its median income, and mean differences in cigarette butts after smoke free zone signs were posted is provided here

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70 Greentree park is situ ated in a predominately African American neighborhood Highland Court Manor, which has the lowest median income of all four parks at $24,948 (City data, 2009). The population is the highest of the four p ark neighborhoods at 2,333 people (City data, 2009). Greentree park had the lowest mean difference between before and after the placement of signage and had the highest p value of 1 00 which was not statistically significant. Roper park is situated in the second lowest median income neighborhood, known as the Duckpond, at $32,520, h owever it is predominately Caucasian with a population of 1,610 (City Data, 2009a). This park had the second lowest mean difference between before and after the placement of sig nage. It had the second lowest p value of 0. 655 which was not statistically significant Northeast park i s the second highest median income neighborhood at $39,506 (City Data, 2009b). The neighborhood, Northeast District, is predominately Caucasian with a populat ion of 1,236. This park had a p value a t 0.109 and was not statistically significant. Possum park is in the neighborhood Appletree and has the highest median income out of all four parks at $44,184 with a small population of 98 (City Data, 2009c). This park had a p value at 0.180 and was not statistically significant. Implications The implications of median income of a neighborhood and mean differences of to note because the two lowest income neighborhood park s sh owed minimal change in collected cigarette butts after smoke free zone signage was introduced and the two higher income neighborhood park s experi enced the greatest decrease in collected cigarette butts once smoke free signage was

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71 introduced. However, none of the parks showed a statistically significant change in amount of cigarette butts collected between baseline and signage conditions There are several factors in which low socio economic factors influence smoking behaviors of park patrons. Manfredi, Cho Crittenden and Dolecek (2007) discuss three factors that limit (ii) weak social norms favoring quittin g and (iii) high daily stress (p. 748). Health concerns rela construct, perceived susceptibility. People who are Low SES are often less educated on the health risks of smoking and secondhand smoke th e n high SES people ( Manfredi, Lacey, Warnecke, & Buis, 1992 ). P ark patrons in low socioeconomic neighborhoods within this study may not believe that other park patrons are in danger of their secondhand smoke, therefore ignoring smoke free zone signs. Research shows that if smoking is a habitual and valued lifestyle in low SES individuals then social norms regarding non smoking may be weaker than smoker s group specific norms and lifestyle s that reinforce their smoking behavior (Cockerham, 2000 ). Howev er, internal need to comply with societal norms ( Montano & Kasprzyk, 2002; Manfredi et al., 1992 ). In regards to the other findings in this research, the perceived severity of smoking in a park with smoke free zone signs reflects park patrons personal thoughts on the consequences associated with their smoking behavior. Some park patrons may have a high severity due to socially related consequences such as a nonsmoker approaching a smoker within a park amenity and referring to the posted smoke free zone signs.

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72 Individuals who are low SES often experience more daily stressors than socio economically advantaged groups ( Gottlieb & Gre en, 1993; Lacey et al., 1993; Romano, Bloom & Syme, 1991; T urner & Avison, 2003 ). Low SES groups experience stressors more frequently, but have fewer resources to control their stress (Gottlieb & Green, 1993; Lacey et al., 1993; Romano, Bloom & Syme, 1991; Turner & Avison, 2003). Therefore, they use cigarette smo king to gain emotional control ( USDHHS, 2001; Todd, 2004 ). If park patrons are stressed, they may be more inclined to seek the perceived benefits of smoking versus dealing with any barriers of smoking. So cioeconomic status is a combination of education, i ncome and occupation (A merican P sychological A ssociation 2012) therefore low income neighborhoods are a part of low socioeconomic status. Current research suggests that people in low SES communities develop academic skills slower than high SES communities (Morgan, Farkas, Hillemeier, & Maczuga, 2009) and that reading competence is correlated with a low literacy environment (Aikens & Barbarin, 2008). Therefore, park patrons in low median income neighborhoods have a higher chance of being less educated and h aving a lower reading literacy than higher income neighborhoods. This is important to note because park patrons in low median income neighborhoods may not be able to read the signs, which are considered the cue to not smoke in park amenities. However, ther e is a universal no smoking graphic on the signs, which may help those with illiteracy. Self 1984). Daily stress is a major barrier for low SES groups in achieving self effic acy (Manfredi et al., 2007). If a park patron has a low self efficacy in their ability to not

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73 smoke in a specific period or place, then most likely they will be unable to refrain from smoking despite the posted smoke free zone signs around park amenities. Posted no smoking signage exemplifies to the park community that compliance is implicit, even as a mere recommendation. A passive method such as recommended no smoking signage may make smokers in the recommended no smoking area feel uncomfortable due to s ocial norms that are promoting compliance This may heighten their perceived seriousness of the behavior and make them stop or move their smoking behavior. Signage that has no ordinance or law backing them may have no other leverage on behavior other than altruism or the formation of new social norms. Therefore, compliance to smoke free zone signage would be based on norms, peer pressure and general rule abiding. Signage may make it easier for non smokers to announce their displeasure with someone smoking a nd ask them to move which may be an unintended positive consequence of this study. Non law enforced signage may be the best option to empower the rights of nonsmokers when states, such as Florida, have preemptive clause legislation. There are currently 12 states with a preemption clause for smoke free air (See Figure A 3 in Appendix A) (Tobacco Prevention Network of Fl, 2011). Due to the preemption clause of the Florida Clean Indoor Air Act, local governance cannot create local laws or ordinances for smoke free air to parks, beaches, recreation areas, music v enues, outdoor workplaces, etc (Tobacco Prevention Network of Fl, 2011). Since the results of this study show almost a 50% decline in cigarette butts in all parks within and around amenities such as pla ygrounds, picn ic pavilions, and restrooms, it may be beneficial to input posted signage into parks, or other areas listed above. However, the author

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74 recommends replication of the study in order to increase confidence so that it can be generalized to other settings. If replication can be reached, then recommendation to local governance should be made. Limitations Th is study has several important limitations Individuals were not the unit of measure within the research but number of cigarette butts found wit hin established amenities. Cigarette butts do not capture all smoking behaviors in public parks; however, cigarette butts are a proxy for smoking behavior (Lee et al., 2011) Therefore, this data collection method does not assess all forms of smoking behav ior. The researcher was also unable to control for cleanup of cigarette butts in public parks by park staff or patrons. Another methodology to use in order to capture smoking behavior is observational data. Researchers could conduct a direct observation s tudy in a natural setting where they would observe human behavior and look for signs of smoking within park amenities. The researchers could do a disguised or non disguised observation. If the researchers did a non disguised, they would be able to follow u p observations with a questionnaire from the park patron. The researcher would have to do several daily observations at each park, which makes it difficult without multiple researchers. In addition, an observational method may not allow the researcher to o bserve all smoking behavior as it may happen most in the evening or afternoon. This study cannot generalize statistically because it i s using a non probability sample, however non (Swisher, 2012, pg 1). It also has a small sample size, which further limits the results to its geographic location and only in public parks.

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75 Ano ther limitation is missing data. The researcher utilized mean substitution to make up for missing data. R esearch shows that replacing missing data with an estimate such as the mean of the observed values for the variable is common (Grace Martin, 2001). surveyed by collecting, counting a nd recording of all cigarette butts. The collection of the cigarette butts may not be completely accurate due to not being able to see them by trash, leaves, dirt or other individuals picking or cleaning them up. Although, c ounting of the cigarette butts o ccurred twice in order to reduce measurement error. The researchers were to measure 25 feet around each amenity for its collection zone. There may be variability due to different amenity layouts; however, the same researchers outlined t he 25 feet around ea ch amenity each time, which helps decrease variability. Despite the s e threat s the study had stron g internal validity because a case control design was used, meaning that the same parks were subjected to the control and intervention treatment. Items such as trash bins remained the same throughout the study. Therefore, if cigarettes were being discarded there in the control, they would still have the same chance of being discarded in the intervention. History threats such as parties within the parks can po ssibly increase the amount of cigarette butts found. However, since the parks remained the same throughout the study the parks had the same chance to have a party during the control period and the intervention period. Future Research The researcher recomm ends that this study be replicated in other park locations. However, the researcher advocates adding an observational component to the current methods in order to account for what effect, or lack of effect is due to the posted

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76 signage. For example, non smo king park patrons may be approaching smoking park patrons in amenities to point out the smoke free zone signage, which may account for the decrease of cigarette butts. It is important to use different seasons to increase confidence that the findings can be generalized to other settings. The researcher also recommends replicating the study and adding a verbal reinforcement component. This may aid in decreasing smoking behaviors in public parks. Due to the additional results that suggested that higher median income neighborhoods experienced a greater reduction in cigarette butts compared to lower income neighborhoods experiencing the least reduction in cigarette butts, the researcher recommends r eplication of this design comparing high SES neighborhoods with low SES neighborhoods. Furthermore, the researcher advises future researcher s to take part in placement of the signs. Due to someone else placing signage in this study, the signs were not placed in the point of decision areas that the researcher wanted. T he r esearcher believes that if signs were properly placed, there may have been a chance for a higher success rate.

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77 APPENDIX A TABLES AND FIGURES Table A 1: Baseline, no s ignage Park Amenity WK1 WK2 WK3 WK4 WK5 WK6 Northeast Restroom 1 2.00 9.00 4.00 17.00 16.00 9.00 Northeast Playground 36.00 31.00 27.00 14.00 23.00 21.00 Northeast Picnic 111.00 79.00 76.00 138.00 95.00 77.00 Possum Playground 27.00 14.00 35.00 20.00 31.00 14.00 Possum P icnic 38.00 14.00 17.00 22.00 26.00 13.00 Gre entree Restroom 1.00 10.00 3.00 5.00 4.00 4.6 0 Greentree Playground 25.00 26.00 26.00 25.00 26.00 25.6 0 Greentree Picnic 16.00 21.00 9.00 17.00 17.00 16 .00 Roper Picnic 44.00 50.00 45.00 54.00 62.00 51 .00 Roper Playground 3.00 3.00 10.00 7.00 6.00 5.8 0 Sums 313.00 257.00 252.00 319.00 306.00 237.00 Averages 31.30 25.70 25.20 31.90 30.60 23.70 Table A 2: Intervention, with s ignage Park Amenity WK7 WK8 WK9 WK10 WK11 WK12 Northeast Restroom 7.20 9.00 7.00 8.00 7.00 5.00 Northeast Playground 10.80 14.00 15.00 17.00 4.00 4.00 Northeast Picnic 37.40 40.00 53.00 51.00 28.00 15.00 Possum Playground 16.80 35.00 25.00 6.00 8.00 10.00 Possum P icnic 15.00 17.00 21.00 9.00 12.00 16.00 Greentree Restroom 8.00 6.00 10.00 4.00 8.00 7.20 Greentree Pl ayground 18.00 13.00 17.00 8.00 8.00 12.80 Greentree Picnic 12.00 9.00 31.00 17.00 13.00 16.40 Roper Picnic 47.00 35.00 31.00 27.00 46.00 37.20 Roper Playground 9.00 4.00 10.00 10.00 3.00 7.20 Sums 181.20 182.00 220.00 157.00 137.00 130.80 Averages 18.12 18.20 22.00 15.70 13.70 13.08 Table A 3 : Amount of signs per amenity in each park Park Amenity Amount of Signs Northeast Restroom 3 Northeast Playground 5 Northeast Picnic 5 Possum Playground 7 Possum P icnic 6 Greentree Restroom 2 Greentree Playground 6 Greentree Picnic 5 Roper Picnic 5 Roper Playground 4

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78 Figure A 1: Average annual number of deaths, 2000 2004 Figure A 2: Secondhand s moke g raphic

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79 Figure A 3: Preemption of local s moke free indoor air o rdinances

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80 APPENDIX B NO SMOKING SIGNAGE Figure B 1 : Example of signage Figure B 2 : Example of signage Figure B 3 : Signage used in project

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81 APPENDIX C PARK SAMPLE SELECTIO N LIST: Table C 1: Park s ample selection l ist PARK AREAS LOCATION PICNIC AREA PLAYGROUND REST ROOMS A.N.N.E. PARK 6224 NW 28 TER X+ X CEDAR GROVE PARK 1200 NE 22 ST CITIZENS FIELD 1400 NE 8 AVE GREEN ACRES PARK 3704 SW 8 AVE X GREENTREE/KIWANI S CHALLENGE 2101 NW 39 AVE X**+ X X L KIWANIS/GIRL SCOUT PA RK NW 8 ST & 8 PL X X LINCOLN PARK 900 SE 15 ST X X L LYNCH PARK 500 BLK S MAIN ST NW 5 AVE PARK 1007 NW 5 AVE X NORTHEAST PARK 501 NE 16 AVE X**+ X X L NORTHEAST 31ST AVE. PARK 1700 NE 31 AVE X** X NORTHEAST COMPLEX 1400 NE 8 AVE NORTHSIDE PARK 5701 NW 34 ST X**+ X X L OAK HILL PARK NW 42 AVE AND NW 9 ST X PHOENIX PARK 2611 SW 31 PL X X POSSUM CREEK PARK 4009 NW 53 AVE X**+ X ALBERT "RAY" MASSEY WESTSIDE PARK 1001 NW 34 ST X**+ X X L ROPER PARK 401 BLK NE 2 ST X ** X SHARMIE FFAR PARK 321 NW 10 ST X X

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82 Table C 1. Continued PARK AREAS LOCATION PICNIC AREA PLAYGROUND REST ROOMS SMOKEY BEAR PARK 2300 NE 15 ST X** X SPRINGHILL PARK 918 SE 5 AVE X SPRINGTREE PARK 2800 NW 39 AVE X** X SWEETWATER PARK 5 00 E UNIVERSITY AVE X** X T.B. MCPHERSON PARK 1717 SE 15 ST X**+ X X L TUMBLIN' CREEK PARK 600 SW 6 ST X**+ X WOODLAWN PARK 1900 SE 4 ST X**+ X B X L TOT LOT #1 NE 4 AV AND 15 ST X**+ X TOT LOT #2 SE 9 ST AND 8 AV X X TOT LOT #3 508 NW 2 ST X **+ X TOT LOT #4 424 NW 6 AVE X TOT LOT #5 (BARBARA HIGGINS PK) 1352 SE 2 ST X**+ X HIDDEN GEM TOT LOT NW 32 PL AND 20 LN X MOTHER LUCILLE PERKINS TOT LOT 318 SW 7 PL X X DOLLIREE BOWENS TOT LOT 820 NW 4 AVE X DUCK POND NW 24 ST 3 00 BLK HIBISCUS PARK 300 BLOCK NW 26 ST DUCK POND NE BLVD PARK WITH FOUNTAIN 10 SW 36 ST GRAND MOTHER LOT (PARK CLOSED) 405 SW 5 AVE

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83 APPENDIX D IRB APPROVAL Figure D 1 : IRB a pproval 1

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84 Figure D 2: IRB a pproval 2

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85 APPENDIX E PHOTOS Figure E 1: Playground s ign Figure E 2: Playground s ign

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86 Figure E 3: Playground s ign Figure E 4: Picnic p avilion s igns

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87 Figure E 5: Picnic p avilion s ign Figure E 6: Playground s ign

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88 Figure E 7: Cigarette b utts Figure E 8: Cigarette b utts

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92 Chaloupka, F.J., Cook, P.J., Peck, R.M., & Tauras, J.A. (2008). Enhancing compliance with tobacco control policies. Retrieved from http://www.sanford.duke.edu/research/papers/SAN08 07.pdf Chapman, S. (2000). Banning smoking outdoor is seldom ethically ju stifiable. Tobacco Control, 9 95 97. Chapman, S. (2007). Evidence, ethics and the future of secondhand smoke policy. Tobacco Control 16, 73e. Chapman, S. (2008). Should smoking in outside public spaces be banned? No. British Medical Journal, 337 76 77. (2005). State smoking restrictions for private sector worksites, restaurants, and bars United States, 1998 and 2004. Morbidity and Mortality Weekly Report, 54 (26), 649 653. Cit y Data. (2009). Highland court manor neighborhood in Gainesville, Florida: 32609 detailed profile. Retrieved from http://www.city data.com/neighborhood/Highland Court Manor Gainesville FL.html City Data. (2009 a ). Duckpond neighborhood in Gainesville, Flori da: 32601 detailed profile. Retrieved from http://www.city data.com/neighborhood/Duckpond Gainesville FL.html City Data. (2009b). Northeast district neighborhood in Gainesville, Florida: 32601 detailed profile. Retrieved from http://www.city data.com/neigh borhood/North East District Gainesville FL.html City Data. (2009c). Appletree neighborhood in Gainesville, Florida: 32653 detailed profile. Retrieved from http://www.city data.com/neighborhood/Appletree Gainesville FL.html Clark, R.N., Burgess, R.L., & Hen dee, J.C. (1975). The development of anti litter behavior in a forest campground. Journal of Applied Behavior Analysis, 5 (1), 1 5. Cockerham W C. (2000). The sociology of health behavior and health lifestyles. In C. Bird P. Conrad A. M. Fremont (Eds. ) Handbook of medical s ociology (pp. 159 72). Upper Saddle River, NJ: Prentice Hall. Committee on Environmental Health. (1997). Environmental tobacco smoke: A hazard to children. Pediatrics, 99 639 642. Coultas, D.B. (1998). Health effects of passive smokin g: 8. Pas sive smoking and risk of adult asthma and COPD: an update. Thorax, 53 (5), 381 387. Crump, S.L., Nunes, D.L., & Crossman, E.K. (1977). The effects of litter on littering behavior in a forest environment. Environment and Behavior, 9 (1), 137 146.

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104 BIOGRAPHICAL SKETCH Heather Nicole Platter was born in April of 1988 in Fort Lauderdale, Florida. She lived in the same house with her parents until she moved to join the Gator Nation at the U niversity of Florida as an undergraduate. Heather was accepted into the M aster of S cience in f amily, y outh, and community s ciences 4+1 program her senior year of her undergraduate program. Heather completed her B achelor of S cience in f amily, y outh, and c ommunity s ciences in 2010 earning Cum Laude. In fall of 2010, Heather continued with her Master of Science degre e along with being accepted into the Master of Public Health certificate program in social and b ehavioral s away suddenly after being diagnosed with lung cancer in May after her first year i n graduate school. This loss in research and teaching. Heather plans to earn a Ph. D. in p ublic h ealth in s ocial and b ehavioral s ciences with a focus on g lobal t obacco c ontrol research and policy. She would eventually like to beco me a professor at a University.